
Class MlO 

Book 3?L 

CopyrightN 



COPYRIGHT DEPOSIT. 



GYN/ECOLOGY 



GYNECOLOGY 



A TEXT-BOOK FOR STUDENTS AND A 
GUIDE FOR PRACTITIONERS 



BY 

WILLIAM R. PRYOR, M. D. 

PROFESSOR OF GYNAECOLOGY IN THE NEW YORK POLYCLINIC MEDICAL 
SCHOOL ; ATTENDING GYNAECOLOGIST NEW YORK POLYCLINIC 
HOSPITAL ; CONSULTING GYNAECOLOGIST ST. VIN- 
CENT'S HOSPITAL, NEW YORK CITY HOSPI- 
TAL, st. Elizabeth's hospital 



ONE HUNDRED AND SIXTY-THREE 
ILLUSTRATIONS IN THE TEXT 



NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1903 



THE LIBRARY OF 
CONGRESS, 

Two Copies Received 

JUL 8 1903 

Copyngnt Entry 
/CLASS Os XXO. No. 

copy a, 



Copyright, 1903 
By D. APPLETON AND COMPANY 

Published June, 1903 



PRINTED AT THE XPPLETCN FRESC 
NEW YORK, U. S. A. 



PKEFAC E 



In writing this book I have tried to limit myself to those sub- 
jects which are strictly gynaecological and upon which a professor 
of gynaecology usually has to lecture. It appeared useless to de- 
scribe fully the very rare diseases, those which even one with a 
large clinic seldom sees, and to picture, either in text or illustra- 
tion, operations now generally abandoned. To do so would be to 
make the work too encyclopaedic. The bibliography so often found 
in gynaecological works would be out of place in a work intended 
for the student and general practitioner; and it is not the prov- 
ince of a gynecologist to illustrate the findings of the microsco- 
pist or of the anatomist. A text-book on diseases peculiar to 
women should describe those diseases and their treatment as fully 
as possible, and such a book I have tried to write. I have at the 
same time so treated the subjects that the work may interest even 
those of large experience. 

The work has been divided into two parts: in the first, the 
diseases are described, and in the latter the operations are given. 
This arrangement, I have thought, will admit of more unbroken 
and symmetrical reading. It will also enable the practical sur- 
geon to find what he wishes without going over unnecessary matter. 

The author has become convinced that works on gynaecology 
are made too general and discuss subjects which properly belong to 
and are better treated of in other departments, notably surgery 
and pathology. It has seemed to him that hut a few pages of the 
modern works upon gynecology are devoted to a description of 
diseases peculiar to women — those upon which a professor of gynae- 
cology in any of the colleges has to lecture. Therefore, a student 
or practitioner, reading one of the modern books upon gynaecol- 
ogy, will become impressed with the fact that there is much over- 
lapping, and that he will have presented for his consideration as 



vi GYNAECOLOGY 

gynaecological, matters which strictly belong to other branches of 
medicine. 

By confining himself strictly to gynaecological topics the author 
has sufficient space to devote to those subjects which are solely 
within his province. 

Most of the illustrations are original and have been made by 
eminent artists, and those which have been borrowed are of equally 
high grade. 

The work is chiefly notable for the absence of bacteriology and 
minute anatomy, and to the prominence given to non-operative 
as well as operative treatment. 



CONTENTS 



CHAPTER I 

PAGE 

Examination of the patient 1 

Taking the history 1 

Examination of the abdomen 1 

Examination by instruments 9 

The dorsal abdominal 9 



CHAPTER II 

The inflammations 14 

Vulvitis 14 

Simple vulvitis 14 

Follicular vulvitis 14 

Gonorrhceal vulvitis 14 

Bartholinitis 16 

Vaginitis 17 

Inflammation of the cervix uteri 19 

Cervical folliculitis 20 

Endocervicitis 20 

Septic endocervicitis . . . 20 

Endometritis 22 

Hematogenous endometritis 23 

Gonorrhceal endometritis 24 

Septic endometritis 26 

Puerperal sepsis 28 

Putrid endometritis 32 

Tuberculosis of the corpus uteri ' ... 34 

Metritis, myometritis 35 

Subinvolution 37 

Hyperinvolution 37 

Peritonitis 38 

Myxomatous peritonitis 46 

Tubercular peritonitis 46 

Salpingitis . • 50 

Acute gonorrhoea] salpingitis 50 

Acute septic salpingitis . ' 53 

Chronic gonorrhceal and septic salpingitis 54 

vii 



Vlll 



GYNAECOLOGY 



Salpingitis : 

Tubercular salpingitis 
Pyosalpinx . . • . 

Inflammations of the ovaries 
Acute oophoritis 
Broad-ligament abscess 
Diffuse pelvic suppuration 



PAGE 

58 
59 
62 
62 
66 



CHAPTER III 



Distortions and displacements . 

Ante version 

Anteflexion 

Simple anteflexion .... 
Anteflexion with retroversion 
Retroversion with retroflexion 
Adherent retrodisplacement . 
Complete prolapse in the parous woman 
Complete prolapse in the nulli parous 
Partial prolapse .... 
Inversion of the uterus . 
Lacerations of the cervix 
Lacerations of the perineum . 



70 
73 
73 
73 
76 
78 
85 
86 
89 
90 
90 
92 
95 



CHAPTER IV 

Diseases of the vulva . . .100 

Vulvo- vaginal cyst 100 

Elephantiasis 100 

Haematoma of vulva 101 

Papillomata or condylomata 101 

Hydrocele 102 

Kraurosis vulva? 102 

Carcinoma of the vulva 103 

The clitoris 103 

Tuberculosis of the vulva 103 

Diseases of the vagina 104 

Vaginal cysts 104 

Condylomata of the vagina 105 

Senile vaginitis . . . .105 

Tuberculosis of the vagina . . 105 

Diseases of the cervix . . . . 106 

Hypertrophy 106 

Supravaginal hypertrophy 106 

Hypertrophy of the infravaginal portion 107 

Cervical condylomata 107 

Tuberculosis of the cervix . . .108 

Vaginismus 108 



COXTEXTS ix 



CHAPTER V 

PAGE 

Fistula 109 

Vesico- vaginal fistula 109 

Uretero- vaginal fistula . .111 

Urethral fistula 113 

Recto-vaginal fistula . 113 

Intervisceral fistula 113 

Abdominal sinus 114 

Abdomino-intestinal or fa?cal fistula 114 

Vagino-intestinal fistula 115 

Diseases of the urethra and bladder 116 

Urethritis ............ 116 

Urethral caruncle 118 

Urethrocele . . . . 119 

Urethral condylomata 119 

Urethral cysts . . 119 

Urethral polypi 119 

Cancer of the urethra 120 

Dilatation of the urethra 121 

Urethral stricture 121 

Cystitis 122 

Chronic cystitis ' . . 124 

Exfoliative cystitis 125 

Tumours of the bladder 125 

Ureteritis 126 

Stricture of the ureter 128 

Cystoscopy 128 

Catheterization of the ureters 130 

Tuberculosis of the bladder 130 

Tuberculosis of the ureter 132 

Vesical calculus 133 

Ureteral calculus 134 



CHAPTER VI 

Tumours op the parovarium and ovary 136 

Parovarian cyst 136 

Hydrocele of the round ligament 138 

Ovarian glandular cyst 138 

Proliferating glandular cyst 138 

Papillomatous ovarian disease 139 

Dermoid of the ovary 141 

Cyst of the corpus luteum 142 

Fibroma of the ovary 144 

Varicocele 144 

Ectopic gestation 144 



GYNECOLOGY 



CHAPTER VII 

PAGE 

Uterine fibromata and fibro-myomata 152 



CHAPTER VIII 

Cancer . . . . . . . . 166 

Cancer of the cervix 167 

Epithelioma 167 

Cancer of the body of the uterus .- „ ■ . 177 

Sarcoma of the uterus . . 180 

Sarcoma of the ovary 182 

Deciduoma malionum 183 



CHAPTER IX 

Dilatation of the cervix 185 

Curettage 187 

Bilateral incision of cervix 192 

Antero-posterior incision of Sims (modified) 193 

Dudley's operation for anteflexion 194 

Amputation of the cervix 195 

Trachelorrhaphy 198 

The conical amputation of Sims . . . . . . . .199 



CHAPTER X 

Perineorrhaphy 201 

Incomplete laceration . . . . , 202 

Anterior colporrhaphy 214 



CHAPTER XI 

The operations for retro-deviations of the uterus .... 216 

CHAPTER XII 

Preparation of patient for capital operations 226 

Abdominal section 227 

Vaginal section 234 

CHAPTER XIII 

Myomectomy 240 

Abdominal 240 

Vaginal 241 

Abdominal hysterectomy for fibroid diseases of the uterus . . 243 

Vaginal ablation of the fibroid uterus 255 



CONTEXTS 



XI 



CHAPTER XIV 

PAtiE 

Ovariotomy 260 

Abdominal .260 

Vaginal 263 

Operations for ectopic gestation 264 

Abdominal ■ 264 

Vaginal 266 



CHAPTER XV 



Conservative operations on the uterine adnexa 

Abdominal .... 

Vaginal 

Abdominal salpingo-oophorect* >m v 

Normal salpingo-oophorectomy 

Simple retention cysts 

In pyosalpinx and ovarian abscess 



269 
270 
273 

278 
279 
279 
280 



CHAPTER XVI 

Management of patients who have been subjected to 
Complications after cceliotomy 

Secondary haemorrhage 

Sepsis after operation 

Ileus 

Suppression of urine 

Nephritis . 

Shock 

Pleurisy . 

Pneumonia 

Tonsilitis . 

Conjunctivitis . 
Drainage after ccelio 
Intravenous injection of normal salt solution 

Subcutaneous injection 



CCELIOTOMY 



284 
287 
287 
288 
292 
294 
295 
295 
295 
295 
296 
296 
296 
297 
299 



CHAPTER XVII 

Hysterectomy for pelvic suppuration 

Abdominal panhysterectomy, abdominal ablation, etc. 

Vaginal hysterectomy, vaginal ablation 

Complications and accidents 

Relative merits of abdominal and vaginal hysterectomy in pus cases 

Vaginal hysterectomy in complete prolapse 

Secondary hemorrhage after vaginal hysterectomy . 



300 
300 
302 
314 
315 
319 
320 



xii GYNECOLOGY 



CHAPTER XVIII 

PAGE 

The operative treatment of carcinoma of the uterus . . . 322 
Indications for the several radical operations for cancer of the 

uterus 322 

Of the cervix uteri 322 

High amputation 333 

The treatment of advanced carcinoma cervicis uteri .... 335 



CHAPTER XIX 

Hernia 338 

Median ventral hernia 338 

Umbilical hernia 341 

Femoral hernia 341 

Inguinal hernia 342 

Suprapubic cystotomy 343 

Infrapubic cystotomy 343 

Operations during pregnancy 344 

Adherent retroposition . . . . . . . . . . 345 

Ovarian cyst 345 

Fibroid tumours . . . . 345 

Cancer of the uterus 346 

Pus foci 347 

Results of castration 347 



CHAPTER XX 

H^mostasis 350 

Pressure 350 

Torsion . . ... 352 

By drugs 352 

Heat 353 

Electro-haemostasis . . . . . . . . . . 353 

Angeiotripsy 354 

Ligation . . . 354 

Haemostasis by forceps 359 

CHAPTER XXI 

Anomalies . . . 360 

General . ... . . 360 

Special . 361 

CHAPTER XXII 

Instruments 370 



LIST OF ILLUSTKATIONS 



FIGURE PAGE 

1. Dorsal position (Pryor) 4 

2. Bimanual method of examination (Pryor) 5 

3. Sims's position (Pryor) 7 

4. Author's position (Pryor) 8 

5. Knee-chest position (Pryor) 9 

6. Trendelenburg position (Pryor) 10 

7. Vulvo- vaginal abscess (Kelly) 16 

8. Cervical erosion (Cullen) . . . 19 

9. Cervical polypi (Winckel) 21 

10. Retained placenta and puerperal sepsis (Pryor) 29 

11. Lesions of gonorrhoea (Pryor) ......... 50 

12. Lesions of chronic gonorrhoea (Pryor) 54 

13. Pachysalpingitis (Winckel) 55 

14. Hydrosalpinx (Pryor) 56 

15. Tubo-ovarian cyst (Pryor) 57 

16. Tubercular salpingitis (Pryor) 58 

17. Lesions of gonorrhoea (Pryor) 62 

18. Graafian follicle hemorrhages (Winckel) 63 

19. Ovarian abscess (Pryor) 63 

20. " Stone " of the ovary (Pryor) . . . ■ . . . . .64 

21. Tubercular ovaritis (Pryor) 65 

22. Section of the pelvis (Deaver) 70 

23. Section of the pelvis (PirogofT) 71 

24. Section of the pelvis (Pirogoff) 72 

25. Simple anteflexion (Pryor) ... 74 

26. Anteflexion with retroversion (Pryor) 77 

27. First step in bimanual replacement (Pryor) 80 

28. Second step in bimanual replacement (Pryor) 80 

29. Third step in bimanual replacement (Pryor) 81 

30. Last step in bimanual replacement (Pryor) 81 

31. Adherent retroposition (Winckel) 85 

32. Complete prolapse of uterus (Tandler) 86 

33. Inversion of uterus (Boivin) 91 

34. The normal cervix (Berry Hart) 93 

35. Cystocele and rectocele (Pryor) 96 

36. Dissection of the perinaeum (Kelly) .98 

37. Complete rupture of the perinaeum (Kelly) 99 

xiii 



xiv GYNECOLOGY 

FIGURE PAGE 

38. Supra-vaginal hypertrophy of cervix (Pryor) 106 

39. Infra-vaginal hypertrophy of cervix (Pryor) 107 

40. Operation for vesico- vaginal fistula (Pryor) 109 

41. The author's method of direct cystoscopy (Pryor) 129 

42. Appearance of ureteral orifice through the author's cystoscope (Pryor). 132 

43. Calculus around a hair-pin (Pryor) 133 

44. Calculus deposit around a catheter-head (Pryor) . . . . . 133 

45. Parovarian cyst (Pryor) 137 

46. Multilocular cyst (Pryor) 139 

47. Papillomatous ovarian cyst (Kelly) 140 

48. Ovarian dermoid (Pryor) 141 

49. Cyst of the corpus luteum (Pryor) 146 

50. Fibroma of the ovaries (Winckel) 147 

51. Unruptured tubal gestation (Pryor) . 149 

52. Ruptured tubal gestation (Pryor) 152 

53. Scheme of uterine fibro-myomata (Pryor) . . . . . . 157 

54. Fibro-myoma uteri (Pryor) 158 

55. Fibro-myoma uteri (Pryor) 159 

56. Fibro-myoma uteri (Pryor) 161 

57. Fibro-myoma uteri (Pryor) . 162 

58. Fibro-cyst of uterus (Pryor) 163 

59. All types of fibro-myoma in one specimen (Pryor) 166 

60. Fibro-myoma of cervix (Roberts) . . . ... . . .167 

61. Squamous cell cancer of cervix (Cullen) . . . . . . .172 

62. Cauliflower growth of cervix (Cullen) 173 

63. Adeno-carcinoma of cervix (Cullen) . . . . . . . .174 

64. Eversion of cervix (Cullen) ......... 178 

65. Tuberculosis of cervix (Cullen) 180 

66. Adeno-carcinoma of body of uterus (Cullen) ...... 182 

67. Sarcoma of body of uterus (Cullen) . . 185 

68. Sarcoma of ovary (Pryor) 186 

69. Forcible dilatation of cervix (Pryor) . 190 

70. Irrigation of uterus (Pryor) 193 

71. Packing the uterus (Pryor) 194 

72. Bilateral incision of cervix (Pryor) 196 

73. Suture of cervix after antero-posterior incision (Pryor) .... 197 

74. Suture of cervix after antero-posterior incision (Pryor) .... 197 

75. Dudley's operation for anteflexion (Pryor) ....... 198 

76. Dudley's operation for anteflexion (Pryor) . . . . . .198 

77. Amputation of cervix (Pryor) . . . . . . ... . 200 

78. Amputation of cervix (Pryor) 201 

79. Amputation of cervix (Pryor) . 201 

80. Amputation of cervix (Pryor) . . 202 

81. Trachelorrhaphy (Pryor) 203 

82. Incomplete laceration of the perinaeum (Pryor) 206 

83. Perineorrhaphy ( Pryor) 207 

84. Perineorrhaphy (Pryor) . .208 

85. Perineorrhaphy (Pryor) 209 



LIST OF ILLUSTRATIONS 



xv 



yor) 



FIGURE 

86. Perineorrhaphy (Pryor) 

87. Emmet's perinaeorrhaphy (Pryor) .... 

88. Emmet's perineorrhaphy (Pryor) .... 

89. Emmet's perineorrhaphy (Pryor) .... 

90. Method of suture in complete laceration of perineum (Pryo 

91. Anterior colporrhaphy — the oval operation (Pryor) 

92. Stoltz's operation (Pryor) 

93. Shortening the round ligaments — Mann's operation (P 

94. Ventro-suspension (Pryor) 

95. Alexander's operation (Pryor) . . . . . 

96. Alexander's operation (Pryor) 

97. Alexander's operation (Pryor) 

98. Alexander's operation (Pryor) 

99. Alexander's operation (Pryor) 

100. Author's operation for retroposition (Pryor) . 

101. Gauze pad (Pryor) 

102. Transverse section of a frozen body (Braune) 

103. Application of the subcuticular suture (Pryor) 

104. Vaginal brush (Pryor) 

105. Incisions around cervix (Pryor) .... 

106. Point of incision into cul-de-sac (Pryor) 

107. Incision into cul-de-sac (Pryor) .... 

108. Closure of vaginal incision (Pryor). 

109. Scheme of ligation of uterine arteries (Pryor) 

110. First step in abdominal hysterectomy (Pryor) 

111. Second step in abdominal hysterectomy (Pryor) . 

112. Third step in abdominal hysterectomy (Pryor) 

113. Fourth step in abdominal hysterectomy (Pryor) . 

114. Last step in abdominal hysterectomy (Pryor) 

115. Abdominal hysterectomy completed (Pryor) . 

116. Retroperitoneal fibroid (Pryor) .... 

117. Fibroid anterior to uterus (Pryor) .... 

118. Scheme of the completed abdominal hysterectomy (Prj 

119. Arterial supply of uterus and adnexa (Spalteholz) 

120. Lateral view of the arterial supply of the pelvis (Spalteholz) 

121. Scheme of vaginal morcellation (Pryor) . 

122. Effect of morcellation on uterus (Pryor) 



123. The morcellated uterus (Pryor) .... 

124. Salpingostomy (Pryor) 

125. Salpingo-oophorectoiny (Pryor) .... 

126. Infusion apparatus (Pryor) 

127. Vessels of elbow (Quain) 

128. Relations of the ureters in vaginal hysterectomy (Tandler and Ilalban) 

129. Hemisection of uterus (Pryor) .... 

130. Hemisection of uterus (Pryor) .... 

131. Hemisection of uterus (Pryor) .... 

132. Hemisection of uterus (Pryor) .... 

133. The pelvic Mikulicz dressing (Pryor) . . . 



or) 



r> 



PAGE 
210 

, 211 
, 212 
, 213 
, 214 
, 218 
218 
, 221 
222 
224 
224 
225 
225 
226 
227 
228 
232 
235 
238 
238 
239 
240 
243 
249 
250 
250 
251 
252 
253 
253 
254 
255 
256 
257 
258 
260 
261 
263 
276 
284 
301 
302 
309 
310 
311 
312 
313 
315 



XVI 



GYNECOLOGY 



FIGURE 

134. The completed operation (Pryor) . 

135. Vaginal hysterectomy for cancer (Pryor) 

136. Vaginal hysterectomy for cancer (Pryor) 

137. Vaginal hysterectomy for cancer (Pryor) 

138. Vaginal hysterectomy for cancer (Pryor) 

139. Specimen removed by vaginal ablation en masse (Pryor) 

140. Specimen removed by the author's operation for cancer 

(Pryor) 

141. High amputation of cervix with cautery (Byrne) . 

142. Skene's method of haemostasis (Skene) . 

143. Section of catgut ligature (Ballance and Edmunds) 

144. Section of catgut (Ballance and Edmunds) . 

145. Section of silk ligature (Ballance and Edmunds) . 

146. Section of silkworm gut (Ballance and Edmunds). 

147. Section of kangaroo tendon (Ballance and Edmunds) 

148. The reef knot (Ballance and Edmunds) . 

149. The stay knot (Ballance and Edmunds). 

150. The stay knot (Ballance and Edmunds). 

151. Pseudo-hermaphrodism (Pozzi) .... 

152. Method of operating upon atresia of vagina . 

153. Double vagina (Kelly) 

154. Uterus sseptus (Gravel) 

155. Bicorn uterus (Kussmaul) 

156. Didelphic uterus (Oliver) . . 

157. Author's operating table (Pryor) .... 

158. Author's operating table (Pryor) .... 

159. Author's hysterectomy clamps (Pryor) . 

160. Illustration of nineteen instruments (Pryor) . 

161. Illustration of twenty-six instruments (Pryor) 

162. Illustration of eighteen instruments (Pryor) . 

163. Illustration of thirty instruments (Pryor) 



of cervix 



PAGE 

, 316 
. 328 
. 329 
. 330 
, 331 
, 332 

336 
338 
357 
359 
359 
360 
360 
361 
362 
362 
362 
365 
366 
367 
367 
368 
368 
370 
370 
371 
371 
372 
373 
374 



GYNAECOLOGY 



CHAPTER I 
EXAMINATION OF THE PATIENT 

Taking" the History. — The physician draws his conclusions from 
facts elicited by questioning the patient and from examination. 
Even an ignorant person when carefully questioned will furnish 
most important evidence. All questions should be asked in a mat- 
ter-of-fact and not too interested manner, for ill women are apt 
to be nervous women, and these are often eager to meet all leading 
questions more than half way. A clear history will frequently 
be the determining factor in making a diagnosis. Too much stress 
cannot be laid upon the proper taking of histories and their preser- 
vation. The history should first proceed with a general statement 
regarding the patient. Then the functions of the several special 
organs are described, after which the results of examination are 
put down. 

Examination of the Abdomen. — This may be made in bed, but 
is preferably done on a table sufficiently long to hold the supine 
body. The movements of the organs should be unhampered by 
tight clothing. The patient should be clothed in her night-gown, 
and when on the table should be covered by a sheet. The gown is 
lifted to the breast-line, and the limbs to the pubis are covered 
by the sheet. The patient should lie perfectly relaxed and breathe 
naturally. Upon inspection we note: the appearance of the skin 
and cutaneous vessels; whether the belly sags laterally or is 
rounded; whether it is symmetrical or distorted by intra-abdomi- 
nal growths; the mobility of the abdominal wall over stationary 
tumours in the abdomen, or the movement of movable tumours 
with respiration. It will also be noted whether the abdomen is 
rigid. 

1 1 



2 GYNECOLOGY 

Date of Consultation. Name. 

Age. Residence. M. S. Wd. 

How long? 

Infantile Diseases. (Nature and dates.) 

Fam i ly H i Story. (Giving ages at death and causes, of two generations. Has a bear- 
ing on vitality.) 

Age of Maturity, Regularity of Menses. (State ail variations up to 

present time.) 

Pain. (During menstruation from maturity to present time.) 

Character of Flow. (Whether clotted, consistence, amount.) 

Duration. (From first appearance to complete cessation.) 

Leucorrhcea. (Amount of douching necessary to keep clean, colour, occurrence, varia- 
bility. Very important in inflammatory and malignant cases.) 

Children. (Number, ages.) 

Character of Labours. (Whether instrumental, presentations, fever after.) 

Miscarriages. (Dates and periods of gestation, causes, fever after.) 

Previous Treatment. (By whom and nature of, particularly operations.) 

Bowels. (Regularity, pain, haemorrhoids, bleeding.) 

Bladder. (Frequency, pain, continence, number of times patient rises at night.) 

History of Present Illness, {Date of onset, symptoms, paying particular atten- 
tion to functions of the special organs.) 

Urinalysis. (Always chemical and microscopic, bacteriological if pus be present.) 

Appearance of Patient. 

( heart 
lungs 
Examination ■{ special organs 

| state of abdominal viscera 
[_ date 



EXAMINATION OF THE PATIEXT 3 

Palpation should proceed methodically and in such a way as 
not to alarm or excite the patient. By superficial palpation 
growths just beneath the surface may be felt, the general or local 
rigidity of the abdomen appreciated, and the integrity of the ab- 
dominal parietes determined. The tactile surfaces of the fingers 
should be employed and not the ends of the fingers. In deep pal- 
pation it is sometimes well to use one hand for feeling only, the 
fingers being held together and pressed down by the other hand. 
In palpating a sensitive spot the pressure should not be released 
suddenly, as this may hurt and startle the patient. Fluid masses 
are appreciated by laying one palm on the side of the abdomen 
and tapping the other side with the other hand. In obese patients 
the semi-fluid fat will also give out a thrill, but this can be elimi- 
nated by the pressure of the edge of an assistant's hand in the 
median line. 

In palpating the appendix the hand is laid on the McBurney 
line near the linea alba and pressed deeply into the abdomen. It 
is then drawn slowly towards the anterior superior spine. As it 
passes over the eaecal region the appendix, if diseased, may be felt, 
or pain elicited. An enlarged uterus is best mapped out by press- 
ing the fingers deeply into the pelvis above and behind the uterus, 
and then by a lateral motion determining the contour of the organ. 
The inguinal glands should always be palpated. In examining the 
kidney I prefer to turn the patient on her side with the proximal 
knee drawn up. thus obtaining complete relaxation of the area to be 
examined. Then one hand is placed over the anterior face of the 
kidney and the other hand behind over the three last ribs. Between 
the two hands the kidney may be felt. The free border of the 
liver and gall bladder should be palpated. The examixer must 

ALWAYS REMEMBER THAT A DISPLACED ORGAX AXD OXE THE SEAT 
OF XEOPLASM XATURALLY MOVES MOST READILY TOWARDS THE XOR- 

mal positiox of the orgax. For instance, the movable kidney 
is displaceable upward, or ovarian cyst downward, etc. Percussion 
will give valuable information in many cases. It will show the 
change in position or fixity of an intestinal note when the body is 
rolled from side to side: the range of mobility in the flat note of 
a tumour ; the size of a dilated stomach or colon ; the presence of 
an omental tumour : the tympanitic note over the liver in rupture 
of the intestine : and the note given out by the contents of hernial 
sacs. Auscultation by the stethoscope will show the friction sound 



4 GYNECOLOGY 

of an ascending peritonitis, whether due to perforation of a typhoid 
ulcer or puerperal septicaemia. It is of great value in the latter 
condition, showing the first onset of diaphragmatic peritonitis. 
By it we may also hear the bruit in the larger fibroid tumours and 
pregnant uterus, as well as the gurgle of gases in the small intes- 
tines. 

When the patient is thrown into the Trendelenburg (Fig. 6) 
position gravity draws the intestines out of the pelvis, so that the 
suprapubic field sinks in. This will tend to bring more promi- 
nently into view pelvic tumours if not adherent deep in the pelvis, 
and will cause movable kidneys and enlarged gall-bladders to sink 
under the protection of the ribs. Consequently this position is 
sometimes employed for the purpose of facilitating palpation of the 

lower abdomen in obscure 
/ /j cases, but it is exceedingly 

§ 4 uncomfortable to the patient. 

The dorsal position en- 
ables us to make a thorough 
examination of the genitals. 
The patient lies on her back 
with loose clothing (Fig. 1). 
The hips are drawn well 
down on the table, so that 

^the feet rest at its edge. The 
|Sj physician should see that the 
^-4/ patient is properly covered 

by a sheet. If the vulva is 

¥i«. L-Thk Dorsal Position. Vei 7 sensitive it should be 

dried off and a piece of cot- 
ton soaking wet in 5-per-cent cocaine solution should be intro- 
duced just within the fourchette and left there ten minutes before 
the examination is made. 

Pelvic Examination. — It is to be noted whether the nymphas 
fall together and close the introitus vagince or whether the vagina 
is gaping. Symmetry or distortion is also to be observed. 

The condition of the anal orifice is seen. Upon gently opening 
the vulva the nymphae, clitoris, urethra, the vulvo-vaginal ducts, 
Skene's tubes, and the perinaeum are inspected. The colour, size, 
and shape of these organs must be noted, together with any dis- 
charges present. 




EXAMINATION OF THE PATIENT 




Fig. 2. — The Combined ok Bimanual 
Method of Examination. 



Combined Method (Fig. 2).— Having thoroughly cleansed his 
hands and lubricated the left index finger, the physician stands to 
the woman's left and introduces his finger into the vagina. The 
left hand is chosen for this 
part of the examination if 
the physician be right-handed, 
and for several reasons. The 
left hand is the smaller, it is 
more flexible, the tactile sensa- 
tion is greater, and the exam- 
ining hand should never be the 
one which must also hold in- 
struments. The tactus erudi- 
tus is better taught the left 
hand, the right hand being 
reserved for manipulation of 
instruments. The examiner 
should stand at the side of the 
pelvis and should never insert but one finger into the vagina. 
It is improper to stand in front of the woman, because ex- 
treme outward rotation of the hand is then impossible and the 
right side of the pelvis cannot be properly palpated. The finger 
notes the condition of the vagina and cervix uteri. The right 
hand is laid with the four fingers touching and the hand open 
above the pubis, and a gentle, steady downward pressure is 
made. Between the two hands thus placed the uterus and its 
adnexa can be palpated. The abdominal hand feels little, it merely 
steadies and depresses the organs. Poking the abdomen with 
the fingers will either cause pain and muscular contraction or will 
tickle the patient, all of which are undesirable and embarrassing. 
The examiner should note the height of the cervix; its position 
between sacrum and pubis; the direction of its canal, whether 
looking in the axis of the vagina or normally backward; the size 
and form of the cervical lips, whether smooth, rough, irregular, 
torn, or enlarged, and whether the cervical canal is closed or 
open. In searching for the body of the uterus always first feel for 
it where it should be. Pass the examining finger anterior to the 
cervix and as high as possible along its anterior face. The 
rounded body of the uterus may be felt, and by a bilateral sweep 
of the finger the contour of the anterior face of the corpus uteri 



6 GYNECOLOGY 

will be made out. The abdominal hand pressing downward and 
the vaginal finger passed beneath the cervix, the entire uterus 
may be palpated between the two hands. Still steadying the organ 
with the right hand, the vaginal finger is passed to one side and 
close to the cervix as high as it will reach. In doing so the con- 
sistence of the broad ligament will be noted. Then swinging the 
finger outward, the hard, often nodular ovary may be felt, easily 
slipping away from pressure. The normal Fallopian tube cannot 
be felt. If a mass is felt on one side, the vaginal finger deter- 
mines whether it is sessile upon the uterus or whether there is a 
distinct sulcus between the mass and the side of the uterus. Pass- 
ing the finger posterior to the cervix, it is made to palpate the pos- 
terior surface of the uterus as high as it will reach and detect any 
growth upon that surface or mass in Douglas's cul-de-sac. If the 
woman be very fleshy or the vagina deep or the abdominal muscles 
held rigid, the knees may be lifted up into the lithotomy posture 
(see Fig. 2). 

This causes the abdominal muscles to relax and stretches the 
tissues over the vulva so as to thin them out. The examiner may 
displace the pelvic floor upward for 2 inches by standing in front 
of the patient, and, bracing his elbow against his hip, crowd his 
hand hard against the vulva. The fingers of the examining hand 
are also displaced into the palm, thus artificially lengthening the 
index finger. In spare women, instead of folding the fingers into 
the palm they may be held straight and passed behind the coccyx. As 
the finger is withdrawn it is to be noted whether it is blood-stained 
or covered by discharge. The colour of the latter is significant ; and 
that the examiner may not be deceived in this, he should employ as 
a lubricant either boroglyceride or white vaseline, or even soap. 

Sims's position (Fig. 3) is employed not so much for un- 
assisted inspection and palpation as for the convenient use of cer- 
tain instruments of examination. It is best secured by the use of 
a special table; but most houses contain a stout table for the pa- 
tient's body and a lighter one for her legs, which will suffice. 
As the object of the posture is to secure the benefits of gravitation 
of the viscera from the pelvis, the waist clothing must be loose. 
Certain essential points may be stated to emphasize the illustra- 
tion: the left trochanter must be at the table's edge; the thighs 
drawn nearly at right angles to the body, the right being higher 
than the left ; the right leg lies in front of the left ; the left arm is 



EXAMINATION OF THE PATIENT 11 

vagina. Gentleness must be used, and when the speculum has 
passed the fourchette 2 inches, it is turned so that one blade is 
posterior, the other anterior. The blades are then separated and 
the cervix brought into view. Through this speculum applications 
to the cervix may be made, cervical cysts punctured, secretions 
secured, and bloodletting from the cervix done; but xo plastic 
operations should be attempted. If Sims's speculum is used 
to depress the posterior wall, the anterior must be held up by 
some form of elevator in nulliparae, not always in multipara?. The 
speculum examination of the vagina in the dorsal position necessi- 
tates opening the vagina against the intra-abdominal pressure, 
therefore Sims's position is always preferable. This necessitates 
the assistance of an attendant to hold the speculum. A long specu- 
lum is selected, one wide enough to prevent the posterior vaginal 
wall folding over it. The assistant with his left hand lifts the 
woman's right buttock and right labium. The operator pulls 
down the left labium and inserts the speculum gently in the axis 
of the vagina. Xo force must be used lest the vaginal membrane 
be lacerated. The assistant now grasps the bar of the speculum 
and draws back the perineum. As he does this the atmospheric 
pressure is released and air enters the vagina, ballooning it out. 
A depressor or forceps holding a swab may be used to still further 
push away the anterior wall, when the cervix will come into view. 
All plastic operations may be done upon the cervix; all opera- 
tions upon the vesico-vaginal saeptum and urethra, as well as the 
cul-de-sac operations, are easily performed in this position. In 
operating upon the uterus it is advisable to use the short Sims's 
speculum to expose the uterus, as with it the uterus can be pulled 
down. This position is the one to be selected in the after-treatment 
of all cases of vaginal hysterectomy and incision, for it is the one 
which takes advantage of natural forces to assist in opening the 
field to be inspected and minimizes the intra-abdominal pressure. 
Or the perinamm may be retracted by a Jackson speculum with 
the patient in the lithotomy position, and the plastic operations 
upon the uterus, partial and complete hysterectomy, removal of 
ovarian cysts, and, in fact, all operations upon the pelvic organs 
which are appropriately performed through the vagina, may be 
done in this position when the perinaeum is retracted by so sim- 
ple and mobile a speculum as Jackson's held by a competent 
assistant. 



12 GYNECOLOGY 

The combined method of examination, or vagina-abdominal, is 
little aided by instrumentation. But sometimes it is necessary to 
hook a pair of blunt bullet forceps into the anterior lip of the 
cervix so as to draw the uterus down, thus enabling the oper- 
ator to more readily map out the organ and its attachments. 
It will be seen that this procedure finds its chief application in 
the manual replacement of the retroverted uterus (Brandt's 
method). 

With the author s position instruments are of the utmost aid. 
After the posterior cul-de-sac is opened, a posterior retractor 
holding down the vaginal wall and the trowel lifting the uterus, 
the operator is enabled to view all the pelvic contents. After the 
completion of a vaginal ablation, by holding aside the stumps 
with Pean's lateral blades, the whole field of operation can be 
inspected. This position" opens up to exploratory and con- 
servative WORK THROUGH THE VAGINA A CLASS OF CASES NOT THUS 
ATTEMPTED BEFORE ITS DISCOVERY. 

Second only to this is its value as a means of direct inspection 
and treatment of the diseased female bladder and ureters. The 
use of the various instruments will be better illustrated under the 
headings of the several operations. 

The Jcnee-chest position, for reasons stated, is undesirable, and 
its value when the examination is assisted by instruments is much 
overestimated. By some it is thought that the position is par- 
ticularly useful in replacing a retroverted uterus. The opposite is 
the fact. The speculum, preferably a Sims's, is introduced into 
the vagina after the patient has been placed in this position and 
the perinseum is raised. The fingers may be used for the same 
purpose. At once the air rushes into the vagina, the viscera leave 
the pelvis as far as their attachments will permit, and the cervix 
uteri recedes from the touch. The body of a retroverted uterus, 
if movable, can no longer be felt and the displacement seems to 
be overcome. Such is not the case. The posterior vaginal wall has 
sought the sacral curve and the anterior approaches the posterior 
aspect of the pubis. The result of assuming this position and 
opening the vagina is to cause the retroverted uterus to become 
more retroverted, the anteverted uterus slightly less so, and the 
uterus as a whole to move farther away from the pelvic outlet. 
The position is useful to assist in the replacement of the gravid, 
retroverted uterus and for the purpose of giving high enemata. 



EXAMINATION OF THE PATIENT 13 

By it also ovarian and broad-ligament congestions are relieved. 
If the patient suddenly turns on her back from this position 
an embarrassing noise may be made by air escaping from the 
vagina. 

Sensitive and prolapsed bnt movable ovaries may also be made 
to assume a higher plane by this position. 

The instrumental examination of the bladder will be described 
in a separate article. 



CHAPTER II 
THE INFLAMMATIONS 

VULVITIS 

Theke are three chief varieties : the simple, the follicular, the 
gonorrhceal. 

Simple vulvitis is seen in adults as the result of lack of clean- 
liness, the germs of putrefaction, the colon bacillus, and the skin 
cocci being present. It may occur as a primary affection or be 
caused by the escape of irritating discharges coming from above. 
It must not be confounded with the redness and swelling due to 
the trauma of riding, bicycling, etc. There is redness, slight swell- 
ing of the nymphas, increase in the mucous discharges from the 
parts, and muco-pus. The tubular-gland orifices appear as small 
red dots. There is often itching, a sense of heaviness about the 
parts, and scalding during urination. The disease is not com- 
mon in adults, but often seen in children, between whom it is 
easily communicable. 

Follicular vulvitis is more often seen as the result of lack of 
cleanliness in women who have diabetes and ammoniacal urine. 
The sebaceous glands become inflamed and discharge pus ; or, their 
mouths being blocked, they produce acne-like pustules. Or the 
mucocutaneous surfaces of the vulva may be bathed in an ill- 
smelling pus. The symptoms are the same as those of simple 
vulvitis, but as this form is seen in older women, as a rule we find 
them less attentive to the annoying symptoms than are the younger 
with simple vulvitis. The presence of this form of vulvitis always 
calls for an analysis of the urine. 

The disease is not seen in children. 

Gonorrheal Vulvitis. — This is by far the most common form. 
The urethra is puffy and red, and upon pressure exudes pus. The 
14 



INFLAMMATIONS OF THE YULVA 



15 



prepuce of the clitoris is ©edematous and the clitoris semi-erect, 
owing to engorgement of its erectile tissue. The tubules of Skene 
appear as red spots, as do the orifices of the single follicles. In 
places the tissues have lost their epithelial covering, but deep 
ulceration does not occur. The ducts of the glands of Bartholin 
are pouting and discharge pus. The glands themselves, one or 
both, may be involved, causing a swelling upon each side which 
is exquisitely sensitive. The tissues are always bathed in pus in 
the acute stage, and in the chronic some inflamed gland-mouths 
may be seen. The microscope always shows the gonococcus; but 
in old cases pressure upon the labia may be necessary to make the 
glands discharge their infected contents. 

The diagnosis of the several forms depends upon the above 
symptoms, often supplemented by the microscope. Where vulvitis 
occurs in hospital wards, particularly among children, the utmost 
caution must be exercised to prevent its spread. In children, ingui- 
nal adenitis is a common result of the gonorrhoeal form. 

The treatment of all forms of vulvitis must be actively pushed. 
Frequent bathing with saturated solution of boric acid will usu- 
ally suffice to cure the simple form. The parts should be kept 
dusted with boric powder. In the gonorrheal form in children 
the same wash should be used, assisted by the daily application 
of nitrate of silver 1 or 2 grains to the ounce of water. If ingui- 
nal adenitis supervenes, it is best treated by unguentum Crede or 
ichthyol ointment 10 per cent. Gonorrhoeal vulvitis in adults 
demands more heroic measures, and is more difficult to cure. In 
view of the destructive lesions produced by it if it extends higher, 
these cases should be kept in bed. If the vulval hair is long it 
should be shaved off, as it conduces to reinfection. Two methods 
of treatment are used by me. The vulva may be thoroughly 
scrubbed with solution of lysol, 1 per cent, then with bichloride 
of mercury (1 to 5,000), afterward using twice a day vulval wash- 
ings of the latter solution. This treatment I apply to hospital cases. 

Or, as in office treatment, the vulva is dried off and then 
carefully moistened with nitrate-of-silver solution, 5 per cent, or 
protargol, 10 per cent. Each day until a cure is effected the vulva 
is painted with either 2-per-cent nitrate of silver or protargol, 
5 per cent. The patient is made to wash the vulva once every eight 
hours with bichloride-of-mercury solution (1 to 10,000), using 
cotton or gauze as a sponge. 



16 



GYNECOLOGY 



BARTHOLINITIS 

Bartholinitis (Fig. 7), or inflammation of the vulvo-vaginal 
gland, produces swelling in the gland, which becomes hard and 
sensitive. In my experience it is invariably of gonorrheal origin, 
these glands having a particular resistant power against other 



,-•"•' 







Fig. 7. — Abscess of Left Vulvo-vaginal Gland (Kelly). 

The distention is in the direction of least resistance, out from the left pubic ramus, partly- 
covering the vaginal outlet. 



pyogenic organisms. The duct of the gland is reddened and pus 
can be squeezed from it if acutely inflamed; if in a chronic state 
there may be no appreciable fluid. If the duct alone is involved 
it should be treated by nitrate of silver, 5 grains to the ounce, 
applied on a filiform probe. If the gland is involved and dis- 



INFLAMMATIONS OF THE VULVA 17 

charging through the duct it should be cocainized and slit open, 
iodoform-gauze dressings being applied afterward several times a 
day to the open wound. If the suppuration be old the entire gland 
should be removed under ether. An incision is made external to 
the vaginal orifice, parallel with it, and over the gland for an 
inch. The gland is carefully dissected out of its bed so as to form 
a pedicle at the upper portion where the nutrient artery enters. 
This is ligated. The wound is to be treated open by iodoform- 
gauze dressings, if pus be present. 

Too much stress cannot be laid upon the importance of radi- 
cally curing every case of gonorrheal vulvitis, and proving the 
cure by bacteriological examination of the discharges secured by 
pressing the tissues, for the germs may lie deep in the glands. 
Chronic latent gonorrheal infection of the vulvo-vaginal glands 
causes much of the spread of this disease. And it is always a 
possible means of acutely reinfecting the woman. 

One of the most disagreeable symptoms of which women with 
simple or follicular vulvitis complain is pruritus. In fact, it is 
often the only symptom which elderly women have. Its pres- 
ence always arouses a suspicion of diabetes. I have secured the 
best results by applying between the labia and nymphae a bit of 
cotton moistened in \ per cent of lysol. An ichthyol ointment of 
5-per-cent strength in lanolin is also effective. In children with 
vulvitis, and who scratch the vulva, worms or irritating clothes 
may be suspected as the cause. 

VAGINITIS 

Vaginitis may occur at any age. It is induced by worms, mas- 
turbation, the flowing down of putrid discharges, as in cancer, and 
by the introduction of the various pathogenic germs. The vagina 
being but an inverted tube of skin with very few if any glands and 
covered by many layers of squamous epithelium, it is particularly 
resistant against germ invasion. At first the membrane becomes 
dry and red and swollen, with elevation of the papillae. After a 
time a watery discharge follows, which soon becomes purulent and 
accompanied by exfoliation of the epithelium. Such are the lesions 
in both the simple vaginitis and the gonorrheal. If the inflamma- 
tion is more intense the elevation of the papillae may be so marked 
as to warrant the name of granular vaginitis. If there is a general 
2 



18 GYNAECOLOGY 

exfoliation of the epithelium the raw surfaces may unite, and this 
form is called adhesive. Another form is the emphysematous, 
characterized by the presence of gas-producing bacilli under the 
epithelium causing gas blisters. 

Vaginitis is not as common as once thought, the membrane 
being able to resist the presence of even large quantities of gonor- 
rhceal pus. In all cases of gonorrhoea it is a complication in about 
15 per cent. The gonorrheal type is seen most often in young 
women, the other forms in middle life. But there are no clean- 
cut differentiations possible without the use of the microscope. 
The symptoms are heat, itching, ardor urinas, dysuria, burning, 
sense of weight, nervousness, and local soreness. The vagina is 
swollen, and there are commonly present the signs of vulvitis. 
There is profuse yellowish or greenish discharge. If gonorrhoea 
be the cause, urethritis is always present. 

Treatment of Gonorrheal Vaginitis. — The patient should go to 
bed. Place her in Sims's position and retract the perinseum. Dry 
the entire vagina carefully and paint it with nitrate of silver, 10 
grains to the ounce in the young, and 20 grains to the ounce in 
older women. The vagina is then packed full of iodoform gauze, 
10-per-cent strength, which has been wrung out in bichloride solu- 
tion (1 to 5,000). The dressing is left in two days and is then 
removed, the patient receiving afterward bichloride douches twice 
a day (1 to 5,000). Or, the only treatment may be one of douches, 
though these do not have the speedy action nor prevent extension 
upward to the uterus which the packing method has. Astringents 
should never be used in the acute cases. In chronic cases sulpho- 
carbolate of zinc (5 to 10 grains to the ounce) may be used as a 
wash, or iodoform-gauze packing. 

The complications to guard against are endometritis, proctitis, 
and cystitis, therefore no instruments should be passed into either 
the uterus, rectum, or bladder during an attack. 

In the form of vaginitis known as senile, seen in old women 
and in the young who have been castrated, the preferable applica- 
tion is some pure grease, as lanolin or sweet-oil. Gas and fluid 
accumulations beneath the epithelium must be evacuated before 
treatment is begun. 

The simple form is best treated by 4-per-cent boric-acid douches 
every six hours. 



INFLAMMATIONS OF THE UTEEUS 



19 



INFLAMMATION OF THE CERVIX UTERI 

The cervix being lined with a true mucous membrane supplied 
with compound racemose glands, it is not often the seat of those 
changes which we call hematogenous, but most forms of inflamma- 




-Cekvical Folliculitis with Eyersion of the Cervical Mucosa — 
"Erosion" (Cullen). 

tion affecting it are due to infections which come from below. 
Those pathogenic germs which exist in the vagina may cause in- 
flammation of the vaginal face of the cervix, but they do not 



20 GYNAECOLOGY 

invade the cervical canal, with one exception — the gonococcus. 
But where the cervix has been torn or cut and its severed lips 
are everted its glands become invaded by any germs which lie in 
the vagina. 

Cervical Folliculitis (Fig. 8). — The follicles about the ex- 
ternal os and on the vaginal face of the cervix have lost their cov- 
ering epithelium and appear as elevated red papillae giving rise 
to an " erosion." Such " erosion " is elevated, not ulcerated, 
and the red elevated papillae do not shade off into the rest of the 
surface, but end sharply. The cervix as a whole is enlarged and 
of deep colour. There is a sense of weight in the pelvis and the 
cervical discharge is increased. The temperature is not elevated. 
The Nabothian follicles may become involved, dilate, and contain 
clear glairy .fluid or pus. The same is true of the glandular folli- 
cles. These changes may be general, producing cystic degeneration 
(Fig. 77), the cysts causing elevations upon the cervix of uniform 
size, which discharge their contents upon being pricked, leaving a 
pock-like depression. In old cases of cystic degeneration, where 
the involvement is general throughout the cervix, a train of disa- 
greeable hysterical symptoms may be present. 

Endocervicitis. — Except where the cervix is rolled outward be- 
cause of tears, all acute primary inflammations of its lining mem- 
brane are due to the gonococcus. In cases of general septic infec- 
tion, or in cervices damaged by labour or operations, the septic cocci 
may cause inflammation. The cervical membrane is also the seat 
of certain slow changes which are designated inflammatory but 
rather appear as new growths. 

Symptoms. — Gonorrhoea! Endocervicitis. — Pelvic tenesmus and 
nervousness are present. The rise in temperature is but a frac- 
tion of a degree, the pulse is not accelerated. Owing to an attend- 
ing vulvitis the symptoms of the latter add to the distress. Upon 
examination we find the cervix of deep colour, the external os 
eroded, and the canal filled by a plug of muco-pus. The least touch 
causes pain. We see the evidences of vulvitis and of urethritis. 

Septic Endocervicitis.— If there be a recent injury to the cervix, 
and this has become septic, the tissues are livid, the raw surfaces 
covered by a pultaceous patch of granulation tissue. There is a 
sanious watery discharge at first, which subsequently becomes puru- 
lent, but the production of pus is not marked. Indeed, the pres- 
ence OF MUCH PUS FROM AN UNWOUNDED CERVIX IS ALMOST PATHOG- 




INFLAMMATIONS OF THE UTEKUS 21 

nomonic or gonorrhcea. After the symptoms have subsided there 
may remain but a slight erosion at the external os or no evidence 
of the past inflammation, and yet deep down in the glands of the 
cervix the cocci may lie. This latency of gonorrheal and septic 
endocervicitis must be borne in mind when operations on the 
cervix are contemplated. In collecting the discharge for examina- 
tion to see if the glands are infected they should always be pressed 
by the fine wire. Lasser found only 9 per cent of cervical mucous 
plugs to contain the gonococcus; but 
when he squeezed the same cervical 
glands he got the gonococcus in 49 
per cent. 

In certain cases the mouths of the 
glands will block up and secretion 
continue. The glandular elements 
continue to grow until the structure 
appears as a polypoid growth hanging 
from the cervix. They are always ** 

J . J Fig. 9.— Cervical Polypi. 

soft and pedunculated, rarely arising 

from the vaginal face of the cervix, but most often from the cer- 
vical canal. They keep the canal open, and upon pressure will 
sometimes recede within it (Fig. 9). They have a tendency if 
neglected to become malignant. Or they may slough and produce 
a putrid discharge. 

Treatment. — In acute cervicitis all cysts must be punctured and 
the vagina lightly packed with antiseptic gauze, or douches of 
formaldehyde (1 to 10,000) or of bichloride of mercury (1 to 
5,000) being given every four hours. If gonorrhcea is suspected, 
it is safer not to douche lest the discharge be washed higher up, 
but to pack around the cervix iodoform gauze wet in bichloride 
solution (1 to 5,000). In acute endocervicitis of gonorrhceal origin 
the pelvic tenesmus is much relieved by stabbing the vaginal face 
of the cervix with a sharp bistoury in a half-dozen places to pro- 
duce local bloodletting. An applicator is then wrapped with cot- 
ton, and after sucking away the plug of purulent pus from the 
cervix by means of a s}nunge, strong tincture of iodine is applied 
to the cervical canal, up to the internal os only, by means of the 
applicator. This powerful diffusible antiseptic speedily destroys 
the gonococci. This application should be made daily until all 
symptoms disappear. 



22 GYNECOLOGY 

In acute septic endocervicitis if a plastic operation lias been 
done all sutures should be removed. Kaw surfaces should be 
painted with pure carbolic acid and an iodoform-gauze packing 
inserted. If the septic endocervicitis exists alone — a rare condition 
— no application is better than the iodine. 

Most cases of endocervicitis are of gonorrheal origin, and the 

DISEASE IS BUT PART OF A GENERAL INVASION OF VULVA AND URE- 
THRA. The danger is that it may extend to the body of the uterus 
and Fallopian tubes, hence no instruments should ever be passed 
through an eroded cervix or one discharging pus, to the cavity 
of the uterus for purposes of examination. 

In chronic gonorrhoeal endocervicitis applications of all known 
germicides often fail to effect a cure. The patient remains in a 
condition which is a menace to herself and others. After all 
simpler means have failed the cervical mucous membrane should 
be excised by Schroeder's or some similar method. Repeated at- 
tacks of gonorrhoeal endocervicitis and the application of strong 
antiseptics will in the course of time result in the production of 
much cicatricial tissue not only in the cervix but also in the peri- 
cervical areolar tissue. 

Polypoid degeneration calls for operative treatment. If the 
polypus arises near the external os it may be clasped and re- 
moved by the cautery wire so as to burn its base. Narcosis is un- 
necessary. But if the polypi are multiple, or the cervical mucous 
membrane shows evidences of producing others, the membrane 
should be excised as high as possible. All such tissues removed 
should be subjected to microscopic examination to exclude or 
detect beginning adeno-carcinoma. The differential diagnosis of 
cervicitis and polypoid degeneration will be found under Cancer 
of the Cervix, with which disease they may be confounded. 

ENDOMETRITIS 

Inflammation of the endometrium is far more important than 
of the cervix, as the internal os is the gateway to the higher 
organs of generation, and infection once having passed this 
point it is almost sure to extend to the tubes or pelvic peritonaeum. 
Pyosalpinx, ovarian abscess, and pelvic peritonitis rarely occur 
except as the result of infection reaching these structures through 
the medium of the uterus. It is an accepted fact that pelvic disease 



INFLAMMATIONS OF THE UTERUS 23 

in women is increasing. This is due to three causes : the un- 
doubted spread of gonorrhoea, the very general dislike to child- 
bearing and the induction of abortion, and to unskilled intra- 
uterine treatment by physicians. 

Endometritis may be described as hematogenous, gonorrhoea^ 
septic, and putrid, according to its aetiology. 

Hematogenous Endometritis. — The endometrium being not a 
mucous membrane but part of the great lymphoid system, we may 
expect that conditions which strongly modify metabolism will be 
revealed in disturbances of growth and function of the endo- 
metrium. 

In phthisis pulmonalis the membrane becomes pale, atrophies, 
and the monthly production of lymphoid cells and blood often 
ceases. This is amenorrhcea. There is a whitish leucorrhoea de- 
void of germ life. 

In gouty women the very opposite is true. Here there is apt 
to be excessive growth of lymphoid elements at each menstruation ; 
the .endometrium is thickened and pours out a moderate amount 
of either whitish leucorrhoea or one darkened by the admixture 
of blood elements. The odour of such a leucorrhoea is apt to be 
offensive. The menstruation is increased. 

In certain forms of cardiac disease, particularly mitral dis- 
ease, the endometrium is often hypertrophied, with a resultant 
monorrhagia. 

Syphilis has a marked effect upon the endometrium. It is as a 
late complication of syphilis that we see round-cell infiltration 
of the endometrium. The membrane becomes thickened and pro- 
duces a profuse whitish leucorrhoea. The menstruation is pain- 
ful, profuse, and clotted, and occasionally intermenstrual bleedings 
are observed. The disease is seen chiefly in women under forty, 
and the differentiation is to be made from cancer. It is not com- 
mon, but should always be borne in mind. It is usually accom- 
panied by general lymphatic enlargements. The uterus is en- 
larged. Fortunately, such women are usually sterile or abort 
early. 

Plasmodium infection (malaria) causes after a time an atrophy 
of the endometrium; the general infectious diseases, as scarla- 
tina and typhoid fever, cause hypertrophy of the endometrium and 
menorrhagia; but all these have but a temporary effect and the 
endometrium returns to a normal condition after they are cured. 



24 GYNECOLOGY 

The treatment of these several forms of endometritis is wholly 
embraced in the treatment of the causative general disease. In 
certain of the incurable diseases, like mitral lesions, the bleeding may 
be so profuse as to demand curettage but without general narcosis. 
When the periods are excessive, and delay is possible, the adminis- 
tration of the dried mammary gland has a restraining influence. 
The various forms of endometritis are mentioned more for the 
purpose of fixing the attention upon their possible existence than 
to illustrate their special treatment, and to show that all 

FORMS OF ENDOMETRITIS ARE NOT DUE TO PATHOGENIC GERMS AND 
DO NOT DEMAND SURGICAL TREATMENT. 

Gonorrhceal Endometritis. — The invariable causative germ is 
the gonococcus. There is a period of from two to four days before 
the symptoms begin after inoculation. Menstruation and intra- 
uterine instrumentation conduce to it. After a time the cocci enter 
the blood-vessels and are found in all parts of the uterine muscu- 
lature. The usual sequelae are peritonitis and salpingitis, the latter 
usually leading to pyosalpinx. Gonorrhceal rheumatism is occa- 
sionally seen to result. 

Symptoms. — There is usually a history of a recent infecting 
coitus. Sharp uterine cramps usher in the disease. These are at 
first intermittent, but soon the pain becomes general over the pel- 
vis. The patient takes to bed as the pain is severe. She lies on 
the back usually with knees drawn up. There is a rapid rise in 
temperature, rarely above 103° F., and the pulse is accelerated, but 
usually below 110. On the first, or at latest the second day there 
appears a profuse discharge, which rapidly becomes purulent. If 
the menses have just ceased the flow of blood may be re-estab- 
lished, and containing much pus. The production of pus is 
greater than we ever see from any other cause. There are ardor 
urince and dysuria. The disease rapidly extends to the Fallo- 
pian tubes, the extension being by direct continuity of tissue. In 
no case of true gonorrhceal endometritis have I failed to find tubal 
disease rapidly supervene. The cases in which this has been 
thought not to be the case were cases of severe endocervicitis, the 
infection stopping at the internal os. Upon examination we find 
signs of gonorrhceal vulvitis, either a drop of pus in the swollen 
urethra, or Bartholinitis, or the reddened cedematous nymphae, 
except when the disease has been introduced by an instrument. 
Upon digital examination the moment the uterus is touched the 



INFLAMMATIONS OF THE UTERUS 25 

patient exclaims. The organ is exquisitely sensitive both to vaginal 
and abdominal touch. This is so great that in most cases it will be 
impossible to make a thorough bimanual examination. But if this 
can be accomplished it will be found that the entire uterus is en- 
larged. In neither broad ligament is there thickening, but deep 
pressure in the lateral fornices will, after the disease has lasted 
several days, show both Fallopian tubes enlarged and sensitive. 
If the speculum is used the cervix is seen as a swollen livid mass, 
its epithelium gone, and a rope of muco-pus protruding from the 
eroded os. In 15 per cent of cases vaginitis will also be found. 
The disease is easily recognised by clinical symptoms, but is proved 
by the microscope. The symptoms subside slowly, the leucorrhcea, 
however, continuing purulent for months. The endometrium re- 
turns to a normal condition, but the inflammation remains in the 
cervical glands. Upon any trauma being inflicted upon the endo- 
metrium, any exposure to cold, menstruation, or excessive coition, 
the endometrium may again become infected with a return of 
symptoms. Or, in rare cases, the infected tubes may leak into the 
uterus, the germs having lost some of their virulence, and we have 
established the nearest approach we have to chronic gonorrheal 
endometritis. As a rule, the endometrium is either acutely in- 
flamed or free from cocci. Chronic gonorrheal endometritis 
without adnexal lesions does not occur. The disease is essen- 
tially one of the non-pregnant uterus. The endometrium may 
entirely regain the normal state, leaving the Fallopian tubes in- 
volved. The discharge of pus may cease, the cervical plug becom- 
ing clear. But in 49 per cent of cases, even though all symptoms 
disappear, the germs will be found in the cervical glands. Re- 
peated infections will ultimately result in the production of either 
pus in the tubes or in connective-tissue hyperplasia. The uterus 
will become a shrunken, hard mass or a large, hard mass of con- 
nective tissue. The endometrium will lose most of its lymphoid 
tissue, this being replaced by connective tissue. I have never seen 
a case of gonorrheal endometritis conceive and go to full term. 
Sterility is the usual result, as seen so commonly in prostitutes. 

Diagnosis. — This is to be made from septic infection. The test 
is finding the gonococcus in the pus from the cervix. But even that 
will not indicate the extent of the infection. 

Treatment. — This may be general and local or by operation. 
If the former is elected, the vulvitis and vaginitis must receive 



26 GYNECOLOGY 

appropriate attention. Local bloodletting from the cervix will 
aid in reducing the congestion. If the cervix will admit the small- 
est Fritsch double-current catheter this should be introduced, and 
the cavity of the uterus washed out with a gallon of bichloride 
solution (1 to 10,000), followed by a gallon of saturated solution 
of boric acid. The patient should be in Sims' s position, the cervix 
steadied by blunt bullet forceps, and the solutions should be of 
110° F. temperature. The boric acid should be used once every 
twelve hours and the bichloride once in a day. The bowels should 
be kept open, particular attention being directed to keeping the 
rectum empty so as to prevent hard scybalous masses pressing upon 
the diseased organs. Opiates may be necessary to allay pain. 
After each bichloride washing the vault of the vagina may be 
painted with ichthyol (20 per cent) in boroglyceride. The local 
bloodletting may be repeated once. The object of this treatment 
is to reduce congestion, allay pain, and by the use of large quanti- 
ties of mild antiseptics to overcome the infection. If the cervix is 
stenosed, or the nervous phenomena such that intra-uterine wash- 
ings are impossible, the local bloodletting, ichthyol, and hot 
douches of J-per-cent lysol must be relied upon. As we seldom 

SEE THESE CASES IN" THE FEW HOURS INTERVENING BETWEEN ONSET 
AND BEFORE INVASION OF THE TUBES THEY ARE USUALLY TO BE 
TREATED AS CASES OF ACUTE GONORRHEAL SALPINGITIS. 

Septic Endometritis. — This is always seen as the result of some 
trauma, or abortion before the third month of gestation. A raw 
surface must have been produced. The causative germs are strep- 
tococci and staphylococci pyogenes. In rare cases other germs 
cause it. The cocci soon penetrate deeply into the endometrium 
and into the lymph spaces of the uterine walls. They extend chiefly 
through the lymph spaces, less actively through the tubes. Fortu- 
nately the disease is not common except following abortion or un- 
fortunate surgery. (See Metritis.) 

Intra-uterine growths which slough may cause it. 

Symptoms. — From twelve hours to three days after the infec- 
tion — the usual period of incubation being somewhat over one day 
and less than two — there is a rise in temperature. This is accom- 
panied by a sense of fulness in the pelvis. Occasionally there is a 
chill. The pelvic fulness in a few hours becomes a severe pain. 
But in large, soft uteri and uteri recently delivered there may be 
absolutely no pain. The constant pain is increased by occasional 



INFLAMMATIONS OF THE UTEEUS 27 

uterine spasms. In a few hours the discharge of pus begins. At 
first it is muco-purulent, but soon becomes apparent!}' pure pus. 
It is not profuse, and may be entirely wanting or only watery. It 
is apt to be blood-stained. Upon examination the absence of vul- 
vitis is noted. The finger passes to the uterus without producing 
pain, but the uterus is very sensitive. Bimanual examination shows 
that the corpus uteri is enlarged and sensitive. The uterus is 
fixed by spasm of its ligaments. After a few days in one or the 
other broad ligament a clenseness and thickening will be felt 
owing to involvement of the lymph streams and overlying peri- 
tonaeum. Or there may be no sensitiveness and no pain; but this 
is seen only in uteri recently delivered and which are soft. 

Upon using the speculum we find the cervix reddened, but not 
markedly so unless wounded. Hanging from the cervix is a muco- 
purulent plug, but there may be no discharge or only a little 
sanious fluid. Wherever there has been exfoliation of epithelium 
on the cervix or vagina there will be a yellowish gray patch. This 
is occasional in staphylococcic infection, but usual in streptococcic. 
If involution of the disease takes place the patient feels better in 
a few days, and may be up in a week. 

.Sequelae. — The most common sequelae are peritonitis, chronic 
metritis, salpingitis, ovarian abscess, abscess of uterine walls, and 
in order of frequency as stated. As a result of the peritonitis the 
uterus if retroposed becomes fixed, the tubes occluded, and the 
adnexa generally fixed. In the gravest cases there are no local 
signs whatever beyond scattered patches of pultaceous false mem- 
brane over spots from which the epithelium has been exfoliated 
and upon other raw surfaces; but there is a profound degree of 
septicaemia with complications remote from the seat of injury, 
such as pneumonia, endocarditis, and nephritis. Death may occur. 

Treatment. — The tendency of authors is to describe but one 
form of septic endometritis — that occurring after abortion or 
labour. Were it not for the surgical accidents this might be true. 
But as we have to deal with the subject in all its phases we must 
describe that form of septic endometritis which is always caused 
by intra-uterine instrumentation and by no other means. If a filthy 
sound has caused it, the uterus should be thoroughly curetted and 
packed full of 10-per-cent iodoform gauze. If an infecting curet- 
tage has been the cause, the field of operation is covered by an 
unseen patch of streptococcus-laden plastic material. This should 



28 GYNECOLOGY 

be curetted away and the uterus packed with iodoform gauze. 
Mere irrigation of the uterus is useless as the cocci lie deeply in 
the endometrium. The object of the curettage is to remove dis- 
eased tissue and to create a raw surface for the absorption of the 
iodine from the iodoform gauze. In these non-puerperal cases 
the uterine muscle is so dense and the lymphatics so little devel- 
oped that, as a rule, septicaemia is not marked, the extension of the 
sepsis being slow. But in many cases where polypi and fibroids 
have been removed in a septic manner, the uterine structure as- 
sumes the characteristics of a puerperal organ, and the treatment 
of such an organ is that of the puerperal septic uterus. It may 
even be necessary, in order to save life, to remove the mutilated 
and infected organ. 

The general treatment must be stimulating; an abundance of 
water to flush the kidneys and assist in the elimination of toxines ; 
strychnine ; whisky ; liquid diet while the temperature is high, and 
bowels kept regular. 

Immediately upon extension of the infection to the adnexa or 
peritonaeum, the exploratory cul-de-sac operation is indicated. 

Puerperal Sepsis (Fig. 10). — This may be defined as a septic 
infection occurring during the puerperal month, after, childbirth, 
or after abortion at or about the third month of gestation. Sepsis 
following abortion in the earlier weeks of pregnancy may be classed 
as septic endometritis. This classification is purely arbitrary, but is 
warranted by the lesions produced by the infection at the two peri- 
ods of gestation, by the results of different lines of treatment, and 
by the complications seen to follow in neglected cases. The more 
virulent pyogenic cocci are present, streptococci or staphylococci. 
Occasionally other germs are found. The infection is at first 
always limited to the placental site or other wounded surface. 
After a time it may become general over the inside of the uterus. 
The clots in the sinuses may become infected, and these infected 
clots may extend high up in the body, forming the state known as 
thrombophlebitis. As a result of infection of the uterine lymph 
spaces we may have the muscle riddled with pus. The infection 
travels through the lymph streams and not through the Fallopian 
tubes. When the infection reaches the lymphatics of the broad 
ligaments it constitutes the state of septic pelvic lymphangitis. 
As a result of this there is a peritonitis of greater or less severity. 
There is produced serum or lymph or pus upon the free surface 



INFLAMMATIONS OF THE UTERUS 



29 



of the peritonaeum. Owing to the continuity of lymph channels 
between the ovary and broad ligament, the ovary may become 
involved, producing acute ovaritis with possible ovarian haemor- 
rhages or abscess. The lymph effused within the pelvis may seal 
up the Fallopian tubes, and these latter becoming infected may 




Fig. 10. — Retained Placenta and Puerperal Sepsis. 

Note the roughened placental site and the smooth surface of the septic endometrium. 

An unusual association of clinical phenomena. 

produce a pyosalpinx. Or there may be a sudden stasis in the 
pelvis and the infection be so severe as to cause death before lymph 
effusion can take place ; and in such a case the only gross lesion to 
be found in the pelvis is a friable livid uterus, upon the interior 
of which is a grayish-yellow patch of false membrane. The char- 



30 GYNECOLOGY 

acteristic general result of this form of infection is septicemia. 
The remote lesions are those which may be expected from such a 
sepsis in such a locality — pleuritis, pneumonitis, endocarditis, 
nephritis. If the lymph breaks down into pus there may be first 
a purulent pelvic peritonitis, later becoming a general purulent 
peritonitis. The causative germs are found in the uterine walls, 
the pelvic lymphatics, occasionally in the blood, and wherever the 
complicating foci of inflammation are seen. 

Symptoms. — There may or may not be a chill. As a rule, the 
temperature and pulse-rate rise steadily and rapidly. There is 
always a higher pulse-rate than can be accounted for by the temper- 
ature, and this is very significant. The face is at first flushed, 
but soon becomes pale and anxious. There is no pain. The lochial 
discharge suddenly ceases or becomes markedly decreased. In its 
place is a watery discharge slightly tinged with pus. There are no 
pelvic symptoms. A speculum examination shows the yellowish 
patch on any denuded surface in the vagina. Albumin early ap- 
pears in the urine and leucocytosis is marked. Fluid taken from 
the interior of the uterus shows the presence of staphylococci or 
streptococci. Upon this examination rests a precise diagnosis and 
the proper treatment. Eecovery may be complete with restoration 
of function in all the pelvic organs, but such a happy result is 
uncommon. Streptococci may also be found in the serum, lymph, 
or pus in the pelvic cavity, occasionally in the blood. 

Sequelce. — Pelvic peritonitis, general peritonitis, ovarian ab- 
scess, pyosalpinx, pleurisy, pneumonia, endocarditis with perma- 
nent heart disease, general lymphatic infection and suppuration, 
acute nephritis, are some of the results of puerperal sepsis. Death 
occurs either from poisoning of the heart muscle or nephritis. It 
is not my purpose to enter into an elaborate discussion of this dis- 
ease, but only to say enough to show the importance of vigorously 
attacking it. Varying with the virulence of the infecting agent, 
the mortality is from 7 to 25 per cent. 

Diagnosis. — This is difficult, and is to be made from general 
conditions which can give the puerperal woman fever, but more 
particularly from putrid infection. The uterus in a suspected 
case should be carefully explored by the finger. In unmixed septic 
infection the interior of the uterus is smooth, and there is no odour 
to the discharge. In putrid infection there will be a roughened 
surface inside the uterus and the discharge will be offensive. Se- 



INFLAMMATIONS OF THE UTERUS 31 

cretion taken from the uterine cavity by Doderlein's tube or some 
similar glass tube will show the exact nature of the infection. 
Too much stress cannot be laid upon this. In putrid infection the 
face is flushed, in septicaemia pale and anxious. In sapraemia the 
pulse is full and bounding, in septicaemia weak and thready. The 
condition in sapraemia is sthenic, in septicaemia there is shock, 
often profound. 

Treatment. — Of all cases of puerperal fever but 25 per cent 
are septic, and of these from 7 to 25 per cent die when let alone, 
according to the virulence of the infecting agent. 1 But in those 
that recover, the morbidity is very high and destructive lesions 
remain. The administration of antistreptococcic serum to these 
cases is followed by a mortality of 33 per cent, while curettage 
alone has a mortality of 22 per cent. So these two methods of 
treatment are to be condemned. The expectant treatment is based 
upon the fact that in most cases but a limited area of the endo- 
metrium is involved, and upon a sublime faith in the resistant 
action of the limiting zone of leucocytes which are arrayed about 
the infected area. The patient is given large quantities of water 
to drink, saline enemata, and an abundance of liquid diet. But 
the essence of the treatment is in the enormous quantities of 
brandy and large doses of strychnine administered. This method 
of treatment seeks the preservation of life only, and has absolutely 
no influence upon the sequelce of the disease. It is therefore re- 
jected by the author, but is far more rational and infinitely less 
dangerous than the mischievous practices of curettage and anti- 
toxine administration. 

The Author's Method of Treatment. — Having observed the de- 
structive action of iodine upon all cocci, the author sought a 
method by which the local and general streptococcic infection 
could be subjected to its influence. It is necessary to have the 
iodine penetrate all parts of the uterine walls. This is secured 
by curetting the uterus and packing it full with 10-per-cent iodo- 
form gauze. In order to obtain a sterilization of the pelvic lym- 
phatics through which the cocci have proceeded, the posterior cul- 
de-sac is opened by a broad incision and the intestines induced to 
leave the pelvis by lowering the patient's head. The pelvis is 
then filled with 5-per-cent iodoform gauze to the level of the 

1 See the report of the Committee of the American Gynaecological Society 
on The Value of Antistreptococcus Serum in Puerperal Sepsis, 1899. 



32 GYNECOLOGY 

tops of the broad ligaments, thus completely isolating the in- 
fected uterus. It is advisable to employ the gauze in snugly 
folded strips so as to facilitate its removal (Fig. 133). In the 
disintegration of the iodoform free iodine is liberated. This is 
readily absorbed both by the inside of the uterus and by the 
peritonaeum, and evidences of systemic saturation are manifested 
within a few hours, the iodine reaction being given by the urine 
and by the saliva. 

Inasmuch as the toxines of the streptococcus have a particularly 
injurious influence upon the kidney, causing acute parenchymatous 
nephritis, it is my practice to close the operation by an intra- 
venous infusion of from Oiv to Ovj of normal saline solution. In 
the after-treatment alcoholic stimulants and saline rectal enemata 
play a prominent part. The intra-uterine packing is removed and 
renewed in three days, to be finally removed' in three days more. 
The cul-de-sac dressings are renewed in a week, and each five days 
thereafter until the cul-de-sac closes. Upon making bacteriolog- 
ical examinations of the dressings from the uterus and pelvis in 
cases proved to be streptococcic, in every one the dressings have 
been shown to be sterile save for the presence of the colon bacillus. 
No case not previously operated upon has died, and many have 
subsequently borne children. 

In view of this experience, I am warranted in saying that 
vaginal and abdominal hysterectomy are positively contra-indicated 
and are uselessly mutilating. Still, hysterectomy is often de- 
manded for the relief of the remote results of puerperal sepsis. 
The treatment of the primary condition must not be confounded 
with that of its sequelae. 

Putrid Endometritis. — Whenever there is dead material within 
the uterus it is apt to become infected by the saprophytic bacilli 
from the vagina. This is particularly true with pieces of secun- 
dines left after labour or abortion, and with polypi and fibroids 
which slough. The bacilli always lie superficially, never penetrate 
the lymph streams, and would be innocuous were it not that their 
site is particularly prone to become the seat of other more danger- 
ous germs. There is slight thickening of the endometrium with 
multiplication of the lymphoid elements. 

Sequela?. — A low form of plastic peritonitis is sometimes seen. 
So long as the case remains simply putrid there is no danger to life. 

Diagnosis. — This is to be made from sepsis. The microscope is 



INFLAMMATIONS OF THE UTEEUS 



33 



the tes^ but the clinical symptoms are sufficiently clear in most 
cases to render confusion impossible. 

Symptoms. — There may be no subjective symptoms. As a rule, 
however, there is a certain amount of saprcemia, which is some- 
times ushered in by a chill, high fever, flushed face, and tense 
pulse. Unless the local conditions which existed previously pro- 
duce it, there is little or no pain. There is a profuse mucous dis- 
charge of ill odour, or purulent and putrid ; but if a purulent dis- 
charge exists, it shows that the case is one of mixed infection. 

Upon examination there is little or no sensitiveness either above 

the uterus or about its adnexa. The cervix is always more or less 

open, and if sufficiently so to admit a finger a rough elevated surface 

can somewhere be felt. The cervix is normal in appearance and the 

subjective symptoms are markedly in disproportion to the local 

lesions. 

Differential Diagnosis 



Onset 

Temperature. . 

Pulse 

Discharge 

False patch . . . 
Complications 

Microscope . . . 

Endometrium 

Leucocv tosis . . 



Puerperal septicaemia. 



Gradual, without chill usually. 

Sometimes chill and repeated. 
If ushered in by chill, high at 

once. Usually gradually and 

continuously rises. 
Rapid from the first, more 

often at or above 120. 
Watery at first ; odourless. 

Purulent later. 
Always wherever epithelium is off . 
Peritonitis, septicaemia, endo- 
carditis, etc. 
Streptococci or staphylococci 

pyogenes. 
Smooth. 

As a rule marked, when the pa- 
tient is near death often not in- 
creased. Violent fluctuations. 



Puerperal sapraemia. 



Chill not usual. 

Maximum soon after onset. 
Usually stationary. 

Rarely above 110. 

Mucous and stinking. 

Never present. 

Rarely in neglected cases ; 

plastic peritonitis. 
Saprophytic bacilli. 

Always rough spot some- 
where. 

Slight increase ; changes 
gradual and not violent. 



Both conditions may exist in the same case. 

Treatment. — The immediate indication is for a removal of the 
putrid mass. If it be a sloughing polypus or fibroid this must be 
removed and at the same time a general curettage should be done. 
If the infection is due to a bit' of retained placenta after abortion or 
labour this spot alone should be curetted, the uterus .washed out 
with saline solution and packed with iodoform gauze. If the case 
is seen late, after the occurrence of peritonitis, curettage and the 
exploratory cul-de-sac operation are indicated. 
3 



34 GYNAECOLOGY 

TUBERCULOSIS OF THE CORPUS UTERI 

This may occur as a primary invasion from the blood, or be 
secondary to a similar disease in the tubes or peritonaeum. The 
disease is particularly apt to occur during the puerperal month, 
the placental site being the starting-point. This is due to auto- 
infection or to the bacilli being introduced by the examining finger 
or instruments. The disease is not infrequent. It usually begins 
at the fundus and extends downward. Ulceration begins soon 
after infiltration of the tissue by cells and bacilli. The ulcers are 
rounded, small, with uneven floors, ragged edges, and a cheesy 
layer at the bottom of the ulcer. All coats of the uterus are in- 
vaded in the course of time. The endometrium first, then the 
entire organ enlarges. The inside of the uterus becomes filled 
with a proliferating mass of granulation tissue which in places 
is deeply ulcerated. The new growth may entirely fill the cavity 
and block the cervix so as to produce a pyometra. 

Symptoms. — There are none that are pathognomonic. The ba- 
cilli can be found in uterine scrapings. Amenorrhcea is very fre- 
quent; lessened menstruation usual, increased rare. Leucorrhcea 
is generally present, occasionally absent, and is muco-purulent. If 
menorrhagia be present the disease will simulate cancer. There is 
very generally an accompanying salpingitis or peritonitis from the 
beginning, whereas these usually follow late in cancer. In pri- 
mary acute tuberculosis of the endometrium, such as supervenes 
during the puerperal month, the diagnosis may be impossible with- 
out the microscope. Tuberculosis occurs before the forty-fifth year, 
while cancer of the corpus uteri is rare before forty. 

The differentiation between the two diseases is not essential, 
as the treatment is the same for both. 

Treatment. — In view of the fact that tubal and peritoneal changes 
so frequently accompany this disease, extirpation of the uterus to- 
gether with the adnexa is indicated. Short of this the best treat- 
ment is curettage supplemented by strong iodoform-gauze uterine 
packing. Iodine has a particularly destructive effect upon tubercle 
bacilli. Vaginal extirpation is preferable to abdominal as being ac- 
companied by less risk of infecting the peritonaeum and less shock. 
But when the general peritoneal cavity is involved abdominal section 
is the indicated operation; and here the uterus is removed merely 
because to leave it and its adnexa is to invite pelvic suppuration later. 



INFLAMMATIONS OF THE UTERUS 35 

METRITIS. MYOMETRITIS 

These terms are used to generically designate the result upon 
the muscular coat of the uterine body of the various infecting 
agents, and of repeated injuries. The words could preferably be 
employed to express certain changes which result from very many 
different destructive agents acting upon the uterus. These results 
may be seen to follow either gonorrhceal or septic inflammation of 
the uterus. They may be due to operative procedures or to syphi- 
lis or to abortion or labour. In fact, almost any agent acting 
energetically upon the uterus, whether mechanical, chemical, or 
of bacterial nature, may produce marked gross changes in the 
uterine muscularis. 

It will be remembered that there is no distinct connective-tissue 
layer lying between the mucosa and muscularis uteri. Consequent- 
ly any severe inflammation of the endometrium will be accompa- 
nied by a more or less marked involvement of the muscularis. 
Metritis of a certain degree always accompanies endometritis when 
the latter is of bacterial origin. 

As is the case in endometritis, we find that many cases of 
metritis are due to the exanthemata; and it is probable that as 
we improve our knowledge of the effect of the eruptive fevers of 
infancy upon the uterus, we will find that the congenital flexures 
and cases of dysmenorrhoea are sequelae of systemic disturbances. 

There may be simply a serous and cellular infiltration of the 
tissues. As a result the connective-tissue elements of the uterus 
are multiplied and the uterus is increased in size. Or the new 
tissue may subsequently contract and thus produce a diminution 
in the size of the organ. The infection may be so severe as to 
cause the death of the migrated cells, and pus be thus produced. 
The pus may be in the form of minute dots or one large abscess 
may form. There may be a general suppuration in all the lymph 
spaces, the uterus being converted into a sponge-like tissue filled 
with pus. The congestion may be so severe as to produce ecchy- 
moses in the endometrium and between the muscular bundles. 
That type of metritis which is characterized by the production of 
much connective tissue is permanent, and the circulation of the 
organ is so modified that at each menstrual epoch sudden sharp 
haemorrhages take place, causing a partial or general exfoliation 
of the endometrium accompanied by severe dysmenorrhoea. 



36 GYNECOLOGY 

When the disease is caused by syphilis the lesions are the same 
as in other syphilitic infiltrations of muscular tissue. 

Symptoms. — From what has been said regarding the association 
between endometritis and metritis it may be inferred that metritis 
is but a stage in the progress of the causative factors of both. 
Therefore, the symptoms attributable to metritis are masked by 
those of the disease of which it is a feature. 

Treatment. — Inasmuch as primary metritis is unknown its 
treatment must be largely if not wholly that of the disease of which 
it is but a stage. In contemplating the pathology of this disease 
we are struck with the fact that no infection of the uterus takes 
place which does not materially injure the muscular walls. The 
damage inflicted upon the muscularis is far greater when the in- 
fecting agent has been' virulent enough to cause salpingitis or 
peritonitis. We cannot look upon the uterus as normal in any 
case of endometritis associated with tubal, ovarian, or peritoneal 
complications ; for it is, apart from the precise and accurate find- 
ings of the microscopist, inconceivable that an infection should 
pass through the uterus of severity sufficient to destroy the tubes 
or produce peritonitis, and still leave the uterus undamaged. 
That the uterine muscle does occasionally recover after such pro- 
nounced infections is shown by the repeated cases of pregnancy fol- 
lowing septicaemia. But it must be remembered that septic in- 
fection of the uterus is usually localized in one part of the organ, 
leaving the rest of it normal, whereas gonorrhceal infection is 
general. Therefore, we find conception occurring after recovery 
from septic metritis, but never after an attack of gonorrhceal 
metritis. 

However, after the causative disease has been appropriately 
treated, much can be done to expedite the recovery of the uterine 
muscle. Treatment is of avail in saving the uterus only in cases 
where the inflammation has resulted in mere cellular hyperplasia. 
When pus, even in microscopic quantities, has been produced in 
the uterine walls, hysterectomy is indicated. The lesser degree of 
•inflammation is improved by occasional depleting punctures into 
the cervix, and the routine application to the vaginal vault of medi- 
cated tampons, preferably those containing ichthyol 10 per cent in 
glycerin. After a mass of cicatricial tissue has been produced no 
treatment is of avail other than hysterectomy, and only a severe 
degree of suffering can warrant this. 



INFLAMMATIONS OF THE UTERUS 37 

Subinvolution. — This term is used to designate the results of an 
incomplete involution of the uterus following miscarriage or la- 
bour. The endometrium is thickened owing to glandular hyper- 
trophy, the muscular cells are enlarged and fatty, the lymph spaces 
distended, and the vessels large. The condition is essentially an 
incomplete physiological state rather than a pathological. The 
organ is soft and enlarged. After a time connective-tissue hyper- 
plasia takes place in the muscular walls. The uterus sinks low 
down in the pelvis, its ligaments stretch, and the veins in the 
broad ligament become distended. As remote secondary lesions 
are the various chronic changes in the ovaries, which follow long- 
standing congestion. 

Symptoms. — The menses are increased, but normal in charac- 
ter and painless. There is present a constant pelvic tenesmus ; and 
backache, dull aching in the thighs, general weariness, costiveness, 
anorexia, and ansemia are common symptoms. A peculiar train of 
nervous phenomena often appears. There may be periods of exci- 
tation followed by melancholia. In extreme cases a suicidal tend- 
ency is manifested. Upon examination the uterus is found low 
down, often retroverted, soft but not sensitive. There is very 
commonly present a milky leucorrhoca in sufficient quantities to 
necessitate douching. 

Treatment. — If the case is seen during the second puerperal 
month, the uterus should be kept up in the pelvis by careful tam- 
ponade or a skilfully fitted pessary. Internally the patient should 
receive quinine and nux vomica with ergot as a tonic and to cause 
shrinkage in the uterus. My prescription for this purpose is : 
Ext. ergotae aquos, gr. f ; ext. nucis vom., gr. -J ; quinine sulph., gr. 
2., t. i. d., a. c. The depleting tamponade of ichthyol (5 per cent) 
with boroglyceride will aid in the treatment. After the condition 
has lasted some months curettage is indicated, to be followed by 
the above treatment. 

Hyperinvolution. — Occasionally after labour or some operation 
like trachelorrhaphy or curettage performed during the puerperal 
month, the uterus begins to shrink rapidly. In a few months the 
organ may be reduced to almost the infantile size. Menses cease 
or are very slight owing to atrophy of the endometrium. If 
menses do occur they are usually very painful. Leucorrhcea is not 
present. Upon examination the hard, small uterus is found high 
in the pelvis. The sound will show that its cavity is less than 2 



38 GYNAECOLOGY 

inches. There is no known treatment of any value as a curative 
agent. Sterility is present, so pregnancy as a cure is out of the 
question. The pain is diminished by the use of ichthyol tampons 
of 10-per-cent strength twice a week. I have seen the dysmenor- 
rhea so severe as to require removal of the uterus. Coincidently 
with this condition the ovaries frequently become sclerosed. 

PERITONITIS 

The peritonaeum becomes deeply injected, its colour varying 
from a delicate pink to a livid hue. Serum is poured out in quan- 
tity, occasionally blood-tinged. The endothelial cells shrink away 
from each other, leaving the underlying lymph spaces exposed. 
White corpuscles, then plasma cells, migrate to the free surface of 
the membrane, where they form masses of " plastic lymph." If 
the process subsides, these flakes of lymph become organized into 
transparent threads or bands or sheets of thin membrane supplied 
by blood-vessels and covered by endothelium. Or the plasma and 
white cells may die, forming pus. The smooth surface of the 
membrane is gone and the exfoliation of endothelial cells may be 
so general as to give to the membrane a granular appearance which 
bleeds upon touch. If pus is produced it is usually odourless, but 
may be putrid or tainted by intestinal gases. 

Causes. — These are direct and contributing . 

Direct. — Peritonitis in women is caused by the gonococcus, 
staphylococcus, streptococcus, pneumococcus, colon bacillus, bacil- 
lus aerogenes capsulatus, saprophytic bacilli, tubercle bacilli, and 
the germs which produce the eruptive fevers. A certain form of 
adhesive peritonitis is produced by various chemical irritants, and 
by trauma inflicted upon the peritonaeum. 

Contributing. — The peritonitis due to the gonococcus we find 
most frequently at the menstrual periods. This is because at this 
time the protecting epithelium of the endometrium is damaged. 
Any injury or trauma inflicted upon the uterus or peritonaeum 
which will facilitate the absorption or extension of germs will 
contribute to peritonitis. Any agent which will produce marked 
venous stasis in the pelvis may cause exfoliation of endothelium 
and migration of germs from the bowel, or from a point where 
they have remained latent. Such an agency is prolonged exposure 
to cold. The mechanical effect of neoplasms rubbing off the endo- 



PERITONITIS 39 

tlielium also conduces to peritonitis. Those germs which are com- 
monly in the large bowel may canse peritonitis in chronic constipa- 
tion. The breaches of surface accompanying abortion and labour 
and operations upon the uterus and intra-peritoneal operations are 
frequently the points at which infection starts and reaches the 
peritonaeum; and the peritonitis occurring under these circum- 
stances is usually septic. 

Manipulation of the viscera during operations may rub off the 
endothelium and lead to peritonitis. A plaque of lymph may be 
effused, the lymph become converted into a sheet of thin mem- 
brane, the underlying peritonaeum continue to pour out serum, and 
in this way a peritoneal cyst be formed. Some of these cysts reach 
a considerable size, even 8 inches in diameter, but as a rule they 
are small. 

Symptoms. — There is at first an effusion of serum. It is im- 
possible to determine its presence upon examination. Plastic 
lymph is next poured out upon the site of infection. Within a few 
hours this becomes organized into a new tissue by the formation 
of delicate capillaries. This lymph tends to hold immobile the 
organs between which it lies. Fixity of the involved area is a 
consequence. If this lymph be produced in quantity it will not only 
fix but will completely isolate the point of infection from the gen- 
eral peritoneal cavity. The less the degree of virulence of the in- 
fecting agent the greater, as a rule, the effusion of lymph, for the 
most virulent germs produce such a circulatory stasis that the 
migration of plasma cells is impossible. If the lymph is effused 
upon the surface of the broad ligaments these are thickened and 
stiffened thereby. As a consequence the uterus which is supported 
by these ligaments becomes also fixed and loses its bilateral mobil- 
ity. Upon examination the lateral vaginal fornices are found to 
have lost their elasticity and in each is a dense infiltration which 
does not fluctuate. 

If the lymph is effused upon one broad ligament only the cervix 
cannot be moved away from the side involved; and if the cervix 
is pulled down it will swing away from the median line, being held 
towards the side inflamed. When the lymph is effused about a 
pus focus or tumour it increases its size and fixes it. Fluid accu- 
mulations may in this way, as a result of repeated infections, be- 
come so inclosed in a mass of lymph as to be mistaken for solid 
tumours. If the effusion has taken place about a hollow viscus in 



40 GYNECOLOGY 

distention this is fixed in this state and cannot contract fully, as is 
seen in the case of the bladder and rectum when so involved. 

The ovaries and tubes remain attached to whatever organs they 
rest against when the lymph is effused about them. 

The lymph is either absorbed or converted into pus or into 
adhesions. The density and firmness of the resulting adhesions 
are much less than would be supposed in view of the very generous 
outpouring of lymph. In addition to binding the organs together 
these adhesions distort the softer tissues, and by constricting nutri- 
ent vessels they cause atrophic changes. The lumen of the Fallo- 
pian tube may be strictured, the ovary shrunken, the ureters ob- 
structed, producing hydro-ureter, and the intestinal peristalsis in- 
terfered with. The new vessels in the adhesions may be so large 
as to be a source of additional blood-supply to the adherent organs. 
In this way omental lipomata are formed, and tumours may be- 
come detached from their original seat and be wholly nourished 
by the vessels of adhesions, and the spleen be in this way much 
enlarged. By means of adhesions the uterus may be fixed in lat- 
eroversion or retroversion. 

Adhesions forming between the pelvic organs and the intestines 
in middle life may, when the atrophy of old age ensues and the 
uterus sinks down into the pelvis, cause serious flexures in the 
bowels. 

The presence of pus free in the peritoneal cavity cannot be de- 
tected upon examination, but when the pus is locked in by a mass 
of lymph it presents the same physical signs as pus in a preformed 
sac. In all cases of purulent peritonitis there is marked oedema 
in all the tissues, which adds to the fixity of the organs, and which 
may extend to the retroperitoneal structures like the muscles of 
the pelvis, or to the cutaneous surface of the abdomen. 

Sensitiveness upon pressure is present in most forms of peri- 
tonitis, but is slight when serum alone is produced, is marked 
when lymph is effused, and most severe when much lymph and 
pus are together produced. But in certain grave forms of primary 
suppurative peritonitis the absence of sensitiveness is notable. 
Muscular rigidity over a spot of peritonitic inflammation is very 
usual and an important sign. 

Tympanites. — This is more or less present in all forms. When 
the peritonitis is acute the oedema and cellular infiltration of the 
intestinal coats interfere with the peristalsis. Later, adhesions 



PERITONITIS 



41 



limit the intestinal movements so that faecal matter is retained and 
putrefies. Certain medication in the treatment of peritonitis, as 
opium, increases the tympany by paralyzing the intestines. 

Pain. — This is slight in the stage of serous effusion, increases 
as lymph is effused, particularly if this is sudden and marked, and 
is greatest in the purulent form. But in primary suppurative peri- 
tonitis of severe type pelvic analgesia is often present. In the 
course of pelvic peritonitis a sudden cessation of the pain accom- 
panied by grave constitutional symptoms often points to a change 
of the inflammation to the purulent type. Pain is always in- 
creased by movements of the body, particularly by contractions of 
the psoas and obturator muscles, and by action of the bowels. 

Temperature. — In the stage of serous effusion the temperature 
is not elevated unless the beginning peritonitis be due to the strep- 
tococcus. As lymph effusion occurs the rise in temperature will 
vary greatly with the kind of infection. In gonorrheal peritonitis 
at this stage the temperature rarely rises to 102.5° F. The same 
is true in the peritonitis due to the colon bacillus and staphylo- 
cocci. A temperature holding steadily about 103° F. for more 
than a day, particularly if occurring as the result of some trauma 
to the uterus or to the peritonaeum, should cause great uneasiness 
in the medical attendant, and is usually due to streptococci. As 
a rule, the evening temperature is somewhat higher than the morn- 
ing. A free elimination of the toxines by the kidneys and bowels 
causes a reduction in temperature. 

Pulse. — This, like the temperature, varies with the infecting 
agent. It is lowest in the peritonitis caused by colon bacilli, gono- 
cocci, and staphylococci, and higher when the more virulent strep- 
tococci and pneumococci are present. The relative marks of tem- 
perature and pulse are important, a high pulse-rate with a com- 
paratively low temperature occurring in those infections which 
produce septicaemia. The mere effusion of serum or lymph does 
not cause the rise in pulse and temperature. We see large quanti- 
ties thrown out about a gauze drain and both temperature and 
pulse remain normal. The disturbance is due to the toxaemia pro- 
duced by the germs which cause the peritonitis. The respiration 
is accelerated and the breathing is thoracic in extensive perito- 
nitis. 

Bigors. — These are not features of peritonitis except when 
there is a sudden elevation of temperature from a point near 101° 



42 GYNECOLOGY 

to one 3° to 4° higher. Eigors are symptoms of general septicae- 
mia rather than of peritonitis. 

Digestion. — There is overproduction of bile, hence overloading 
the stomach may result in vomiting. Otherwise vomiting is not a 
symptom of pelvic peritonitis unless suppurative. The higher the 
invasion of the peritonaeum the greater the tendency to vomit. 
Persistent vomiting, accompanied by high pulse and fever, points 
to an ascending peritonitis. The stomach may reject the liquid 
and foods taken, or vomiting may occur even when the stomach is 
empty. The vomitus may be clear and watery, or greenish or 
brown bile, or blood-stained from haemorrhages into the stomach, 
or even stercoraceous. As a rule, in peritonitis there is a disposi- 
tion to hyperacidity with fermentation of starch foods and sweets. 
Animal broths and red meats are well borne. The bowels are usu- 
ally confined for reasons stated, but in septic peritonitis diarrhoea 
is common. 

The mind is clear in even fatal peritonitis until the very last 
hours, when muttering delirium occurs. Active delirium is un- 
usual. The fades are those of one in pain, but in deep sepsis the 
face is pale and apathetic, as of one in great shock. 

The kidneys are not directly affected by peritonitis. If the peri- 
tonitis be due to streptococci, acute parenchymatous nephritis is 
a common complication. 

Peritonitis due to streptococci may be accompanied by other 
remote lesions produced by that germ, such as endocarditis, 
pneumonia, and pleurisy. In fact, it is not usual for a case 
of streptococcic peritonitis to recover without some grave com- 
plication. 

Death from peritonitis is immediately due to the poisonous 
effect of the toxines upon the heart muscle. 

Diagnosis. — This is not difficult after the effusion of lymph 
occurs. The chief difficulty is found in determining when pus is 
produced and when the inflammation ceases to be pelvic and has 
become general. Purulent peritonitis is usually preceded by abor- 
tion, labour, or some trauma to the abdominal or pelvic organs. 
A pulse above 110, temperature at 103° F., pale apathetic face, 
sordes on teeth, dry coated tongue, slight delirium, uterus fixed in 
pelvis, vaginal vault arched and hard with a boggy mass in the 
posterior cul-de-sac, point to suppurative pelvic peritonitis. Peri- 
tonitis due to gonococcus is accompanied by symptoms of gonor- 



PERITOXITIS 43 

rhoea of the vulva and tubes. Peritonitis due to the colon bacillus 
is usually of gradual onset and not discovered before plastic effu- 
sion has taken place. In abdominal peritonitis the muscles over 
the inflamed area become rigid and resistant to pressure. With 
the stethoscope crepitus can sometimes be heard in the early 
stage of plastic effusion. In all forms of peritonitis there is 
leucocytosis, but in cases near death the leucocyte count may 
rapidly fall. Peritonitis due to streptococci gives the highest 
leucocyte count, the lowest accompanying peritonitis due to the 
colon bacillus. 

Prognosis. — When the inflammation produces serum and lymph 
only, recovery is the rule. In certain rapidly fatal streptococ- 
cic cases death ensues before inflammatory products are effused. 
Most cases of primary suppurative peritonitis die unless operated 
upon, and even with operation they are apt to die. The prognosis 
is governed by the virulence of the infecting agent, the amount of 
it introduced, the state of the locality injured, and the general 
condition of the patient. Peritonitis in those suffering from car- 
diac disease, from diabetes, and from nephritis, is particularly fatal. 
Peritonitis following criminal abortion and instrumental deliver- 
ies, and all intra-abdominal operations in which there is much 
crushing and bruising of the tissues, is of severe type. The peri- 
tonaeum when uninjured has marvellous resistant power. The peri- 
tonitis may be limited to a certain area, as the pelvis, known as 
pelvic peritonitis, or be designated by an organ it surrounds, and 
be known as peri-oophoritis, perimetritis, periproctitis, etc.; or 
it may be general. As a rule, the higher the seat of inflammation 
the greater the clanger. Certain areas of the peritonaeum are 
particularly resistant, notably the covering of the colon and that 
of the pelvic organs. The peritonitis due to sloughing fibroids, 
ovarian cysts with twisted pedicles, ruptured dermoid cysts, and 
ruptured pyosalpinx, is of a particularly virulent type. 

Treatment. — From what has been said regarding the causes of 
peritonitis, it will be seen that the author is not one of those 
who believes in idiopathic peritonitis, and that he looks upon peri- 
tonitis as an exponent of an infectious process rather than as a 
disease per se. Therefore, whatever treatment is adopted must be 
in the light of the cause of the peritonitis. In fact, peritonitis is 
rather a protective and beneficent process, an attempt on the 
part of Nature to check and limit an invasion by harmful agents. 



44 GYNECOLOGY 

The method adopted by the peritonaeum is very effective in most 
cases, though remotely injurious, and the lesions produced by peri- 
tonitis show the extent of this. 

Although it is more precise to treat the cause of the peritonitis, 
yet it is desirable also to limit the peritoneal effusion at the same 
time. Hence, surgeons have begun to not only cleanse the point 
of entrance of the noxious germs, but also coincidently to enter 
the peritoneal pouch. 

I believe that any treatment of peritonitis is incomplete which 
does not at the same time attack the infecting agent. 

The treatment of pelvic peritonitis embraces agents which act 
indirectly and those which are applied directly to the inflamed 
membrane. 

Among the indirect methods of treatment by far the most ef- 
fective is the cleansing by operation and antiseptics of the point 
of entrance of the infecting germs. These cleansing methods will 
be described in other places. Of the other agents which act indi- 
rectly the most potent is cold. This may be applied as an ice-bag 
over the lower abdomen, or as a continuous vaginal irrigation of 
water cooled to 60° F. Cold furthermore causes contraction in 
the unstriped musculature of the deeper organs and dilatation by 
paralysis of the superficial capillaries. It therefore is a depleting 
agent. Cold increases pain for the first few moments of its appli- 
cation, after which it diminishes it. It limits the amount of 
lymph effused but apparently increases the serum, and has no 
effect upon the suppurative type of peritonitis. Next to cold, heat 
is the most efficient, indirect controlling agent of peritonitis. It 
is applied by abdominal poultice and vaginal douche. Heat has 
little effect upon the acute inflammation, but is of undoubted effi- 
cacy in chronic peritonitis, more accurately expressed as subacute 
peritonitis. Here the vaso-motor nerves are stimulated, blood in 
stasis drawn away from the inflamed area, and the flow of fresh 
blood to the part induced. To accomplish this the abdominal 
poultice must be of flaxseed meal and as hot as can be borne, and 
the vaginal douche of not less than 110° F., and repeated every 
few hours. This method of treating subacute pelvic peritonitis 
must be persisted in so long as the disease lasts, often for years. 
It is a makeshift, nothing more nor less. 

Local bloodletting by depleting the peritonaeum tends to limit 
the peritoneal effusion in the pelvis and reduces the pain. It is 



PERITONITIS 45 

obtained in pelvic peritonitis by puncturing the cervix and can be 
protracted by hot vaginal douching. 

The pelvic congestion is much lessened if the rectum is kept 
empty by enemata. These also reduce the pain by removing scyb- 
alous masses which press upon the diseased organ. 

The application of local antiseptics which are absorbed, such as 
ichthyol glycerin on tampons, not only reduces pain but also tends 
to limit the peritoneal effusion. Any agent which slows the heart's 
action and contracts the arterioles will reduce the pain and lessen 
the production of serum and lymph. Such agents are aconite, anti- 
pijrine, and other coal-tar derivatives. Opium should never be 
used in peritonitis if it can possibly be avoided. It undoubtedly 
prevents mobility between and spasm in the tissues underlying the 
inflamed peritonaeum, but it produces a most disagreeable reten- 
tion toxicosis. By it the bowels are locked up, the stomach diges- 
tion spoiled, tympany induced, and the entire body tone lowered. 
It relieves pain, but this is a borrowed relief which must be paid 
back later by vomiting, tympanites, and costiveness, and medica- 
tion to relieve these. Certain symptoms of peritonitis are much 
relieved by medication and nursing. The temperature and pulse- 
rate are lowered by increasing the quantity of urine and flushing 
out the colon. Both are accomplished by the daily administration 
of mild doses of saline laxatives, the ingestion of large quantities 
of water, and by high enemata of normal salt solution. I am 
opposed to the administration of drastic purges. In a series of 
cases of streptococcus peritonitis the first high saline enema was 
followed by an average fall of 1.5° F. in temperature and ten 
pulsations of the heart. Agents which sustain the vital forces 
and increase cellular activity aid the tissue resistance. Such are 
moderate doses of brandy and strychnine. The attempt to cure 
peritonitis by this very old method of treatment and by keep- 
ing the woman drunk and half-poisoned by strychnine is to be 
deprecated. 

The hysterical symptoms occasionally seen in peritonitis are 
best controlled by hyoscyamus or hyoscyamina. 

The posture of the patient should be supine, the limbs should 
be kept still, as to move them is to contract the psoas and iliacus 
muscles, and the pelvis should be elevated except in suppurative 
peritonitis. Whenever there is a suspicion of pelvic suppuration 
the head and shoulders should be elevated so as to keep within the 



46 GYNECOLOGY 

pelvis all the fluid products of the inflammation. Peritonitis oc- 
curring about an ovarian cyst whose pedicle has twisted or about 
a sloughing fibroid tumour, calls for the immediate section of the 
abdomen and removal of the cause. 

The treatment of post-operative peritonitis and of those forms 
of peritonitis which occur in conjunction with pelvic inflammations 
will be separately considered. 

Myxomatous Peritonitis. — This rare disease is also known as 
gelatinous peritonitis and pseudomyxomatous peritonitis. The 
peritonasum is thickened and of deeper colour than normal. There 
is little serum and fibrin produced, but a great quantity of straw- 
yellow, transparent gelatinous material. This lies loose in the 
peritoneal cavity, from which it may be scooped out in masses. 
At certain points the jelly may have a whitish colour due to the 
admixture of fibrin. The jelly is secreted by the peritoneal endo- 
thelium. The disease is usually secondary to myxomatous degen- 
eration of some abdominal organ, as the ovary, but is reported to 
occur primarily. My belief is that it is always secondary. It is 
essentially chronic in its course. The patient notices a steady 
increase in abdominal enlargement, which is painless, accompa- 
nied by no temperature and devoid of general debility. Or, if 
a small ovarian cyst of this nature ruptures, there may be more 
or less of temporal shock, and then the progressive abdominal 
enlargement. The symptoms and signs are nearly those of ascites ; 
but fluctuation and change of fluid level by posture is not usual 
in myxomatous peritonitis. Having found such a condition dur- 
ing an operation all the gelatinous material should be removed by 
means of the hand, followed by saline irrigation of the peritoneal 
cavity. 

Then a careful search should be made for the usual cyst 
of the ovary whose rupture has led to the disease. I have seen 
3 cases of this disease, in one of which there was recurrence of 
the affection in seven years. After the operation drainage is 
unnecessary. 

Tubercular Peritonitis. — Tubercular peritonitis occurs as sec- 
ondary to miliary tuberculosis of the lungs, and is then hemato- 
genous, or as an extension from some pelvic or abdominal organ, and 
is then lymphagenous, or very rarely as a primary affection. When 
the infection comes to the peritonaeum through the blood the 
grayish tubercles of rounded form and equal size become implanted 



PERITONITIS 47 

beneath the unbroken endothelial cells. When the bacilli come 
through the lymphatics there is greater disturbance of the mem- 
brane ; it becomes hyperaemic and the endothelium proliferates, and 
there is produced a copious serous transudation often tinged with 
blood. Sometimes the lymphagenous type particularly affects 
the lymphatics of the mesenteries of the viscera and gives rise to 
rapidly growing tumour masses. The disease may remain local 
for a long time and spontaneous recovery take place, but it usually 
shows a tendency to become general. The effusion may be either 
serous, plastic, or purulent, in the latter event being always a 
mixed infection. The effused lymph binds and mats the organs 
together, and the amount of fibrinous material may be so great 
as to form a mass filling the abdomen through which the intes- 
tines extend as permanently distended burrows. Clinically the dis- 
ease is divided into three classes: the miliary, the fibrinous or 
caseous, and the lymphatic. All types may be found in the same 
case. The disease may occur at any age, but is most common be- 
tween the ages of twenty and forty. It is most common in the 
negress, and about 50 per cent of the cases are inherited. It sel- 
dom produces general tuberculosis. 

We find it secondary to lung tuberculosis, to intestinal tubercu- 
losis, to tuberculosis of the uterus, and as a most acute process 
occurring post partum. Often the origin is so obscure that it 
appears primary. The organ over which the affected peritonaeum 
lies often becomes much thickened, notably in the case of the omen- 
tum. The peritonaeum is much thickened, loses its elasticity, and 
is easily peeled from the abdominal parietes. In colour it may be 
pale in the miliary type, but when thickened it is of a deep red hue. 
In the lymphatic type the organs under the inflamed membrane 
become exceedingly friable and tear even under gentle handling. 
In the fibrinous type the adherent organs show no " plane of cleav- 
age " through which they may be separated, but are so glued 
together that attempts to separate them either tear the thickened 
peritonaeum or the underlying tissue. 

Symptoms. — By far the most constant symptom is pain. It 
is present most of the time with occasional sudden and violent 
exacerbations. The pain is usually over the seat of infection, but 
if there is much involvement of the peritonaeum over the small in- 
testines, the pain radiates about the umbilicus. If the peritonaeum 
of the pelvis is involved there will be dysmenorrhoea and other 



48 GYNECOLOGY 

functional disturbances. (See Tuberculosis of the Uterus, Ova- 
ries, and Tubes.) 

Tympany is commonly present, the intestines being continually 
distended by gases. Constipation is usual. In certain cases there 
will be noticed a progressive abdominal enlargement. If this be 
due to great serous effusion the enlargement will be elastic and 
have other symptoms of ascites. If the enlargement be due to 
tubercular glandular growth there may be presented a rapidly 
growing solid tumour immovably fixed and about which is much 
fluid. If there be fibrinous peritonitis the entire abdomen may 
be filled with a solid tumour through which course tympanitic 
areas, which latter do not change relations to the tumour upon 
change in posture. 

Very often pain and frequency in urination are present. 

Usually fever is present. It is least apt to appear in the mil- 
iary form of the disease unless general, is commonly present in the 
fibrinous, and always high in the lymphatic and purulent types. 

The pulse corresponds to the temperature. 

In general appearance many patients appear perfectly healthy, 
particularly if the disease be miliary. In the fibrinous and lym- 
phatic types emaciation is the rule. The disease if lymphatic often 
assumes the type of irregular malarial infection with repeated 
chills and fever. At best, however, the symptoms of tubercular 
peritonitis are not clear, and a diagnosis must be arrived at largely 
by exclusion. One observation of importance is that unless pus 
be present tubercular peritonitis does not produce leucocytosis, 
but causes a mild secondary anaemia. Upon examination, in mil- 
iary tuberculosis the symptoms are exactly those of ascites. But 
there is absence of the usual causes of ascites and the subject of 
tubercular peritonitis is usually younger than would be one having 
liver or other disease sufficient to cause ascites. 

In the lymphatic type and in the fibrinous form of the disease 
the abdominal enlargement very often assumes the characteristics 
of an abdominal tumour, but devoid of mobility. The chills, the 
fever, the pain, and the usually rapid progress of the case will 
aid in the differentiation. 

Owing to the frequency of abdominal and pelvic tuber- 
culosis, WHENEVER A PATIENT PRESENTS IN WHOM THE CAU 3E OF 
AN EXISTING ASCITES IS NOT KNOWN, AN EXPLORATORY ABDC MTNAL 
SECTION IS INDICATED. 



PEEITOOTTIS 49 

Treatment. — There is no known medical treatment of tubercu- 
lar peritonitis. The pain may be relieved by codeine or other 
opium derivatives, and other distressing symptoms alleviated by 
appropriate remedies. The disease always calls for an abdominal 
section except when it is known that it is confined to the pelvis, 
and that the uterus and its adnexa are so involved as to de- 
mand removal. The operator must evacuate all fluid and wash 
out the abdominal cavity with large quantities of normal salt solu- 
tion, and close the abdomen without drainage. If the case be one 
of miliary tuberculosis limited to a small area of peritonaeum, 
I am in the habit of allowing a piece of iodoform gauze (20-per-cent 
strength) to rest upon it while applying the sutures, removing this 
gauze just before tying the sutures. A cure is effected in about 
30 per cent of cases where the disease is not general, and in many 
of those. The manner in which a cure is effected is not positively 
known. It is my opinion that the release of intra-abdominal pres- 
sure by the section and evacuation of fluid, allowing as it does a 
sudden marked influx of fresh blood to the peritonaeum, destroys 
the bacilli. If the case be found to be one in which there is ad- 
vanced involvement of the subperitoneal tissues, particularly of the 
mesenteric glands, a cure is not to be expected. Likewise if the 
intestines be matted together by fibrinous material a cure is very 
rare. In the lymphatic type the abdomen should at once be closed 
after evacuating the serum. In the fibrinous type, if the intes- 
tines are matted together, no attempt should be made to free them. 
In 2 such cases where I was enabled to work down to the pelvic 
floor I introduced a large drain of iodoform gauze. The iodism 
following this effected a cure. In no case where there is much 
serous effusion should drainage be employed, for a permanent fis- 
tula may result, and it is most difficult to prevent the drain 
becoming infected. Therefore drainage is not to be employed 
in the miliary type, rarely in the fibrinous, and never in the 
lymphatic form of the disease. It is unwise to remove ovaries 
or tubes the peritoneal covering of which is involved, unless they 
are structurally diseased. In their removal great care must be em- 
ployed in the manipulation, for the tissues are almost as friable 
as in cancer. The application of ligatures must be made deep down 
in the pelvis for the same reason. 



50 



GYNAECOLOGY 



SALPINGITIS 

Gonorrheal salpingitis. . . \ acut 
( cl 



3hronic 
acute 
chronic 
Tubercular salpingitis . . . chronic 



Septic salpingitis. 



Acute Gonorrhoea! Salpingitis (Fig. 11). — The disease is caused 
by gonococci introduced into the vagina by a man who is suffering 
from either an acute gonorrhoea or a gleet, or is due to the activity 
of " latent gonorrhoea " in the woman herself, or is introduced by 
examination or instrumentation. The disease is always bilateral, 
though the involvement may not be the same on both sides. There 
is at first oedema and congestion of all the coats of the tube. As 




Fig. 11. — Acute Bilateral Gonoreikeal Salpingitis. Vaginal Ablation. 



the infection reaches the fimbriated end of the tube the fimbriae 
fold into the lumen of the tube, a local peritonitis results, and 
the tube becomes closed by agglutination between the approxi- 
mated peritoneal surfaces. The results of inflammation are always 
at first purulent, and, being thus locked in there is formed a 
purulent salpingitis, then a purulent " retention cyst " or pyosal- 
pinx. The production of pus may be very little and of serum great ; 
the pus cells may entirely disappear, leaving the tube distended 
by serum forming a hydrosalpinx. But hydrosalpinx from gonor- 
rhoeal infection is rare. Or there may be great production of 
connective tissue in the tubal walls with constrictions of the lumen 



SALPINGITIS 51 

and permanent distortions, forming pachysalpingitis or tubal scle- 
rosis, which may coexist with pyosalpinx. The endothelial covering 
of the tube exfoliates, leaving the subperitoneal coat exposed, deeply 
injected, and rough-appearing from isolated spots of lymph effu- 
sion. A greater or less degree of pelvic peritonitis is always pres- 
ent. Gronococci may be found in all coats of the tube. 

At first the tube is exceedingly friable, is deeply discoloured, 
and tears easily. Upon section it is found that most of the thick- 
ening is due to cellular and fluid infiltration of the walls of the 
tube, and that the lumen is not much distended. The oedema is so 
great that often the tubal rugae are obliterated as separate folds. 
At first the creamy pus escapes from the tube into the uterus, but 
after a time the uterine opening of the tube becomes obliterated 
and the pus is retained. 

Eestoration to a normal condition without surgical intervention 
is rare, some permanent alteration in the tube being usual. The 
heavy organ sinks low down behind the broad ligament, where it 
and the ovary, owing to adhesive peritonitis, may form a conglomer- 
ate mass plastered to the broad ligament or uterus. 

Symptoms. — We usually see evidences of a recent gonorrhceal 
urethritis or vulvitis, and gonorrhceal endometritis is always pres- 
ent. In addition to the symptoms of the coexisting complications, 
the acute inflammation of the tube produces spasmodic pains in 
the tubal regions which radiate downward and to the thighs. After 
the muscular spasm in the tubes is stopped by the intensity of the 
inflammation and oedema the pain in the affected side becomes con- 
tinuous. The pain may also be of a boring character through the 
corresponding sacro-iliac joint. The rectal temperature rarely 
goes above 103° F., and the pulse commonly ranges below 110° F. 
Nausea and vomiting are occasional. Owing to the coexisting peri- 
tonitis the bowels become inactive and t} 7 mpanites results. The 
symptoms are most severe up to about the fifth day, but after that 
partial local analgesia is produced by the fluid and cellular infil- 
tration of the tissues. The disease is always bilateral. Upon 
vaginal examination the lateral fornices are found tense and the 
uterus fixed by inflammatory exudate and muscular spasm. The 
diseased organs are most sensitive to pressure, and it is impossi- 
ble to exactly map out their contour. In fact, it is improper to 
inflict such injury upon them as accompanies a thorough bimanual 
examination. 



52 GYNAECOLOGY 

Diagnosis. — The history, the evidences of gonorrhoea elsewhere, 
the absence of trauma to the uterus, the presence of bilateral pelvic 
peritonitis, not preceded by abortion or labour, corroborated by 
the microscopic finding of the gonococcus, make the diagnosis 
cleaT and easy. The differentiation is to be made from the vari- 
ous pelvic neuralgias, ectopic gestation, sepsis, intraligamentous 
fibroids, and small suppurating ovarian cysts. 

Upon exploratory vaginal section, serum and lymph flakes es- 
cape. After inserting the finger the tender recent attachments 
between the organs are felt and easily broken, and thick creamy 
pus may escape as the fimbriated ends of the tubes are liberated. 
The exact contour and relations of the involved tube can be easily 
appreciated. As the false attachments are broken slight paren- 
chymatous oozing results. Upon inspection the signs of intense 
inflammation described above are found. 

Upon exploratory abdominal section the tympanitic intes- 
tines are first encountered. Upon lifting the omentum the fun- 
dus uteri is seen, to which may be attached the sigmoid, the 
appendix vermiformis, knuckles of small intestines, or the omen- 
tum. The adhesions are readily broken into, and after lifting 
the intestines the diseased tubes will be found usually deep down 
in the pelvis behind the broad ligaments and uterus. They are 
frequently found to be completely hidden from view by the ag- 
glutinated mass of superimposed omentum and intestines, and 
this must be proceeded through before the organs sought can 
be inspected. 

Treatment. — When an acute gonorrheal salpingitis has oc- 
curred one of two plans may be followed : the case may be treated 
expectantly. It will be found that the pain is lessened if the rec- 
tum is kept free from scybalous masses that press upon the tubes. 
Local bloodletting from the cervix reduces the vascular tension. 
If the vault of the vagina and cervix are painted with 20-per-cent 
ichthyol in glycerin, in a few hours slight local anaesthetic effect 
is induced. An ice-bag over the suprapubic region affords some 
patients relief. Others find that very hot douches and poultices 
give comfort. 

The douches should be mildly antiseptic, preferably lysol (i 
per cent) or bichloride of mercury (1 to 10,000). Poultices, ice- 
bags, and douches have no controlling action upon the infection. 
Local bloodletting and ichthyol every other clay somewhat aid the 



SALPINGITIS 53 

tissues in their resistance to the germs. The surgical treatment 
embraces the evacuation of the products of inflammation by curet- 
tage and the posterior vaginal section, vaginal ablation, or ab- 
dominal section and removal of the diseased organs. In first at- 
tacks the curettage and vaginal section are indicated. After 
repeated attacks the repair power of the tubes is so damaged that 
the radical vaginal or abdominal operation is indicated. Pyosal- 
pinx never forms if the cul-de-sac is opened as soon as it is found 
that the infection has extended outside the uterus, and the tubes 
treated through the incision. This operation prevents suppura- 
tion, the expectant treatment encourages it. 

Sequelae- . — The neglected cases go on to the formation of a 
sacculated pyosalpinx, or pachysalpingitis, or a combination of 
both, very rarely to form a hydrosalpinx — all with many adhe- 
sions. Long-standing tubal suppuration may induce a similar pro- 
cess in the adjacent ovary. 

Acute Septic Salpingitis. — The usual causative germs are 
staphylococci or streptococci. Sometimes these reach the tube by 
extension along the lining membrane of the uterus. As a rule, 
however, there is first a pelvic peritonitis due to the extension 
of a sepsis by way of the lymphatics from the endometrium, then a 
secondary salpingitis. Therefore we most often see this form of 
salpingitis occurring after abortion or labour, in which states 
the lymphatics are particularly active. Occasionally, owing to un- 
clean intra-uterine operations, an ectopic sac will become infected 
and produce an acute septic salpingitis. 

The gross lesions produced by this form of infection are iden- 
tical with those of the gonorrhceal. The microscope alone will 
differentiate the cause. The disease is often unilateral. 

Symptoms. — There is always a history of a wound to the ute- 
rus, either by an instrument or abortion or labour. The onset is 
frequently ushered in by a chill. The temperature rises rapidly 
and the pulse is high. A temperature of 102° to 10-i F. and a 
pulse usually over 110 are the rule. The subjective symptoms are 
the same as accompany gonorrhceal salpingitis. There is no ac- 
companying urethritis and vulvitis. Whenever the epithelium is 
off the cervix or vagina a patch of false membrane is seen if strep- 
tococci are present. The accompanying endometritis produces a 
watery pus rather than the profuse thick discharge of gonorrhoea. 
The vaginal section and abdominal section show the same lesions 



54 GYNAECOLOGY 

as are found in gonorrhoeal salpingitis, except that one side of 
the pelvis may be f onnd perfectly normal. 

The possibility of a mixed infection by both gonorrhoeal and 
septic germs must not be forgotten. 

Sequelce. — Acute septic salpingitis either runs into a chronic 
state or produces an ovarian abscess or a general septicaemia, 
sometimes fatal, or resolves with the absorption of the pus and the 
production of a hydrosalpinx or the conversion of the tube into a 
pachysalpingitis. Most cases of hydrosalpinx are due to sepsis. 

Treatment. — There are two lines of treatment, the expectant 
and the surgical. The expectant treatment is the same as that for 
gonorrhoeal salpingitis, only it should be supplemented by the in- 
ternal administration of stimulants to meet the graver constitu- 
tional effects of sepsis. 

The surgical treatment embraces curettage of the uterus and 
the posterior cul-de-sac incision with drainage in all cases where 
the infection has not produced distinct pus pockets, or the vaginal 
or abdominal removal of the inflamed organs. Far better ulti- 
mate results are obtained by conservative treatment of septic sal- 
pingitis than of gonorrhoeal, and no matter how gravely ill the 
subject is, the conservative vaginal section is always preferable to 
the removal of any organs. In cases many times infected, in those 
relapsing after conservatism, and where the infection has pro- 
duced a diffuse suppuration, 
a radical operation with free 
drainage is indicated. 

Chronic Gonorrhoeal and 
Septic Salpingitis (Fig. 12). 
— Unless checked by surgical 
means gonorrhoeal and septic 
salpingitis always leave the 
tube permanently damaged. 
,., .. n n n A repetition of the infection 

Iig. 12. — Chronic Gonorrheal and Septic 

Salpingitis. Cystic Ovary. ma y result in the production 

of much connective tissue, con- 
stituting pachysalpingitis. Very rarely in gonorrhoea, often in 
sepsis, particularly staphylococcic, both ends of the tube will be 
occluded, and secretion continuing, there will be produced a clear 
cyst of retention, a hydrosalpinx. The most destructive lesion of 
the tube resulting from these infections is pyosalpinx. Then the 




SALPINGITIS 



55 



tubal walls form but the retaining membrane of a pus pocket. They 
are firm though perhaps thinned. The plicae of the tube are ob- 
literated, the lining being little more than a pyogenic membrane. 
Coexisting with a pyosalpinx may be an ovarian abscess or dif- 
fuse pelvic suppuration. The precise differences both in lesions 




Fig. 13. — Pachysalpingitis, Multiple Peritoneal Adhesions, Ovarian Sclerosis. 

It will be noted that the tubes have, by repeated infections, been converted into mere 

fibrous cords (Winckel). 

and treatment vary according to whether the production of con- 
nective tissue or pus or simple fluid predominates. 

Pachysalpingitis (Fig. 13). — The lumen of the tube is much 
diminished in size, is wholly obliterated or constricted in places. 
The tube is tortuous, bound by adhesions, is cord-like, and pale 
in colour. Usually there have been many attacks of endometritis 



56 



GYNECOLOGY 



or repeated curettages. The menses are much diminished, and 
there is slight leucorrhcea. The pelvic pain is pretty constant, 
increasing before menstruation. There is no fever and the patients 
are usually well nourished. Dysmenorrhea is severe, and sterility 
is always present when the condition is bilateral, the usual state. . 
The condition is very common in prostitutes. Upon examina- 
tion the uterus is usually fixed high in the pelvis, is decreased in 
size, and the vaginal f ornices are drawn to the cervix by cicatricial 
tissue. Occasionally the uterus is enlarged. The tubes are felt as 
cords extending from the cornua, and are sensitive upon pressure. 
The ovaries are rarely to be felt. There is a fixity about these 
uteri without evidences of effusion which is significant. The pain 
is produced by the connective tissue constricting the nerves. If the 
cul-de-sac is opened the dense character and inelasticity of the tis- 
sues are apparent. Many firm old bands are felt in the pelvis 
which are broken with difficulty. The tubes appear as firm, white, 




Fig. 14. — Hydrosalpinx. 



occluded, often knobbed cords, not pink, as in health, nor livid, as 
in acute salpingitis, nor brawny, as are pus tubes. 

Treatment. — A cure is not to be effected except by removal. 
Ichthyol (10 per cent) may be injected into the vagina at bed- 



SALPINGITIS 



57 



time every other night by means of a straight " P-syringe," or a 
tampon soaked in the same solution may be applied over the cervix, 
to relieve pain. The lesions are permanent and progressive. 

Hydrosalpinx (Fig. 14). — The cyst walls are very thin. There 
may be one large cyst, or the tube may be sacculated. The tube 
may vary from one but slightly above normal in size to one weigh- 




Fig. 15. — Tcbo-oyarian Cyst. 

Shows the opening in the tube communicating with the cyst of the ovary. Th 
cyst has been cut open. 



tubal 



ing many ounces. The contents are clear fluid, sometimes with 
flakes of desquamated epithelium. Occasionally a calculus is 
found in the fluid. If a hydrosalpinx communicates with the 
cavity of a simple follicular degeneration of the ovary it consti- 
tutes a tubo-or avian cyst (Fig. 15). Hydrosalpinx is of slow for- 
mation and is produced by any condition which will close the fim- 
briated end of the tube. It will sometimes form in the stump left 
after an imperfectly performed salpingectomy. 

The symptoms are not clear. The primary cause is an infec- 
tion which is usually septic and mild. There are no attacks of 
repeated peritonitis. There is no fever. The pain is occasional. 
Rarelv a tube will discharge into the uterus and the contents thus 



58 



GYNECOLOGY 



escape. Upon examination a hydrosalpinx is felt as a very thin- 
walled cyst, distinctly pedunculate, and rather freely movable. 
They are not very sensitive, and are often ruptured during ex- 
amination with no ill effect. Upon inspecting a hydrosalpinx 
through the vaginal incision its characteristics are remarked, the 
absence of all signs of acute inflammation, the perfectly smooth 
surface covered by endothelium, and the thin wall through which 
the fluid shows. 

Treatment. — If the sacs are large they should be removed, the 
ovary being spared if possible. They may be removed either 
through the vagina or through the abdomen. If the tube is not 
distended beyond a diameter of an inch, the tube should not be 
sacrificed, but a salpingostomy should be done. 

Tubercular Salpingitis (Fig. 16). — It is found in about 1 per 
cent of deaths from natural causes, and in 4 per cent of cases 
dying of phthisis. It is most frequent be- 
tween twenty and forty. The disease is 
usually bilateral. There may be scattered 
tubercles lying beneath the mucous mem- 
brane of the tube; or the tubercular proc- 
ess may extend to the muscular coat of 
the tube with extensive caseation, and per- 
haps the formation of a tubercular pyosal- 
pinx; or there may be an extensive pro- 
duction of fibrous tissue between the tuber- 
cles, causing great distention of the tubal 
lumen. The second form is most com- 
mon. Calcareous plates are sometimes 
found in the cheesy material. The type 
of this disease is very chronic, acute mili- 
ary tuberculosis of the tubes being ex- 
ceedingly rare. Most cases are accompa- 
nied by a plastic peritonitis about the fim- 
briated ends of the tubes. Tuberculosis 
of the tubes is the most common form of 
tuberculosis of the generative tract. About 10 per cent of all 
pyosalpinx cases show tubercles. The disease is very often accom- 
panied by tubercular peritonitis; and tubercular tubes are found 
in about 35 per cent of all cases of tubercular peritonitis in 
women. 




Fig. 16. — Tubercular Sal- 
pingitis. 

Shows both miliary tubercles 
and cheesy ulcerations. 



SALPINGITIS 59 

Symptoms. — They are those of a simple catarrhal salpingitis 
of very chronic type, or of a pyosalpinx which has formed very 
slowly and without the history of gonorrhoea or sepsis. The symp- 
toms are always less acute than in other forms of salpingitis. 
Tubercular pyosalpinx is firmer and less sensitive than other forms. 
The morning temperature is often subnormal and that at night 
elevated, and the daily variations are very regular. 

Treatment. — Merely evacuative incision of tubercular pyosal- 
pinx often causes a systemic infection by the bacilli. It is there- 
fore better in all cases to perform a radical operation either by the 
vagina or the abdomen. The latter route is preferable where the 
general peritonaeum is involved, owing to the destructive effect of 
the abdominal section upon the bacilli in such cases. 

Pyosalpinx. — This is a purulent cyst of retention, and should 
not be confounded with acute purulent salpingitis. The walls 
of the tube are hard and thinned, or they may be much thickened. 
Through them the yellowish pus within often shows. The vessels 
are dilated, and upon the tube flakes of lymph are seen, some of 
which have been converted into firm adhesions. The tube is broad- 
est at the ampulla, where it is usually attached either to the ovary 
or the broad ligament, and at the cornu it is narrow and firm. 
Therefore a pyosalpinx is pedunculate. Sometimes the adjacent 
ovary is normal, but more often it, too, is inflamed. Upon section 
of one of these old pus-tubes the tubal plicae may be present or 
obliterated, and the sole lining of the tube be a so-called pyogenic 
membrane. The pus filling them is in about a third of the cases 
sterile, but usually contains micro-organisms. The most common 
is the gonococcus. The tubercle bacillus is found in about 10 per 
cent of cases, and other organisms less frequently. The cavity 
of the tube may communicate with one in the ovary. Or there 
may be a fistulous tract between the pus-tube and the rectum, 
vagina, bladder, or appendix vermiformis, due to rupture of the 
pyosalpinx into either viscus. The tube may rupture into the 
mass of lymph effusion which forms in the pelvis, producing diffuse 
suppuration with its innumerable sinuses. Pyosalpinx may result 
from a salpingitis, be secondary to an appendicitis if on the right 
side, be secondary to a pelvic lymphangitis or ovaritis, or be due to 
suppuration in an ectopic sac. Patients with pyosalpinx may carry 
them for 3 r ears with little impairment of health. These pus sacs 
are secure from trauma deep within the bony pelvis, and only 



60 GYNAECOLOGY 

occasionally do they rupture. If the rupture takes place into the 
bowel, the most frequent point of evacuation, a sudden relief from 
symptoms is experienced, but relapse is usual by reinfection from 
the bowel. Or the rupture may occur into the vagina or bladder, 
and relapse be less likely. If a pus-tube ruptures into the free 
pelvic cavity (a rare occurrence), it is rapidly fatal unless an 
operation is done. As a rule, before intraperitoneal rupture can 
occur, dense masses of plastic material will have been effused about 
the weak point, and when rupture occurs the pus is kept locked in. 

Symptoms.— There is the history of the primary infection, with 
subsequent relapses. Pretty constantly pain in the pelvis exists. 
Intercourse, exercise, and sudden body movements increase it. A 
few days before menstruation the pain begins to increase, but 
diminishes when the flow is established. The pain is of a dull 
character, radiating through the back and down the thigh. Before 
menstruation it may become of a stabbing character. The menses 
are increased in amount. A purulent leucorrhcea is present. The 
patient is sterile. Menstruation may remain regular, but more 
often irregular bleedings occur. These are due to the irritating 
presence of adhesions, which keep the uterus enlarged. There is 
also usually an increase in the amount of menstrual blood, and this 
is apt to clot. Recurrent attacks of inflammation are usual, and 
relapse occurs soon after the first attack. The evening tempera- 
ture is elevated and the pulse accelerated in most cases. Leucocy- 
tosis is present. The cause of these relapses is probably the escape 
of pus or the migration of germs from the abscess. 

Upon examination there is felt in one or the other lateral 
vaginal fornix a fixed sensitive mass posterior to the broad liga- 
ment, and having a distinct sulcus between it and the uterus. Or 
the mass may be behind the uterus. It feels to the finger like a 
thick-walled sac filled with fluid. The uterus also is fixed, and may 
be displaced if the pus sac be large. Upon abdominal exploration, 
the intestines which mask the sac must be released and held back. 
This is not necessary in vaginal exploration. The finger is passed 
along the posterior surface of the uterus, then laterally, and in 
this way the contour, size, and attachments of the sac are deter- 
mined. On inspection the discoloured sac shows bleeding points 
where adhesions were severed, and bits of lymph adhere to it. 

Diagnosis. — First there is the history of the infection. A sup- 
purating ovarian cyst is usually much larger than a pyosalpinx, 



SALPINGITIS 61 

and is unilateral. It is usually infected from above, not from 
below by gonorrhoea or by infecting trauma to the uterus. An 
ectopic sac is harder than a pyosalpinx, the subjective symptoms 
are different, there is no fever,, etc. A broad-ligament cyst or ab- 
scess is always sessile upon the uterus, and occupies a position ante- 
rior as well as posterior to the normal plane of the broad ligament. 
Appendicitis may coexist with pyosalpinx and will mask its symp- 
toms. Appendicular pain is abdominal, and radiates upward 
towards the xiphoid; pyosalpinx pain radiates downward. In ap- 
pendicitis the greatest sensitiveness is upon abdominal pressure 
over the appendix; in pyosalpinx vaginal examination develops 
the greatest sensitiveness. In appendicitis muscular rigidity over 
the appendix is marked; it is absent in pyosalpinx. Intraperito- 
neal hematoma presents none of the subjective symptoms of inflam- 
mation until it becomes infected. Tubercular tubal disease cannot 
be differentiated except by the history. Tubercular salpingitis is 
usually of very slow formation, except when occurring post par turn, 
does not present the acute symptoms which attend tubal inflamma- 
tion from other causes, and is not accompanied by the purulent 
leucorrhcea attending gonorrhoeal salpingitis. Very often the ex- 
amination of the specimen after removal will alone differentiate. 
Treatment. — The existence of pyosalpinx requires a surgical 
operation. This may be either a vaginal evacuation or an abdom- 
inal removal. A single pyosalpinx cannot be satisfactorily removed 
through the vagina. If the disease be bilateral, either a vaginal 
ablation or abdominal removal may be performed. If the patient 
be very much reduced, the pus should be evacuated per vaginam, 
and the strength improved before she undergoes a severe opera- 
tion. If the history shows that the pus has discharged into the 
rectum, vaginal incisions should be made and the rectum kept 
open so as to facilitate the closure of the fistula before doing the 
operation of removal of the sac. As a rule, such cases call for the 
radical vaginal operation rather than laparotomy. In treating 
these cases, it must be remembered that surgical rules govern here 
as elsewhere, and that suppuration in - a preformed sac is cured 

EITHER BY REMOVAL OF THE SAC OR ITS OBLITERATION. 

Prognosis. — The pus may become cheesy and remain quiescent. 
Usually, however, a condition of chronic invalidism is induced, 
leading to nephritis and phthisis. Pus sacs which rupture into the 
bowel often produce profound septicaemia from passage of the 



62 



GYNECOLOGY 



bowel contents into the tube. These and the cases of diffuse suppu- 
ration are the gravest. The peritonitis accompanying the suppu- 
ration interferes with the bowel and bladder functions. 



INFLAMMATIONS OF THE OVARIES 

Acute Oophoritis. — Any agent which produces peritonitis adja- 
cent to the ovary may also cause an inflammation of the peritoneal 
covering of the ovary. We therefore find the condition frequently 
associated with septic endometritis, salpingitis, pelvic peritonitis, 
or on the right side with appendicitis, and it also occurs as a 




Fig. 17. 



-Acute Salpingitis, Chronic Salpingitis, Acute Oophoritis, Acute 
Pelvic Peritonitis. Vaginal Ablation by Hemisection. 



complication of the eruptive fevers. If the peritonaeum only 
is involved it is known as peri- oophoritis (Fig. 17). There is 
an effusion of lymph over the ovary which may bind it to any 
adjacent organ, most frequently the broad ligament or tube. The 
ovary is swollen and cedematous. The lymph may break down 
into pus or become organized into bands or sheets of adhesions 
which constrict or conceal the ovary. As a result of the inflam- 
mation the capsule of the ovary becomes thickened. If the in- 
flammation extends to the stroma of the ovary the organ becomes 
much swollen and cedematous from serous and cellular infiltration. 
The inflammation and the accompanying congestion may be so 
intense as to produce haemorrhages into the stroma, constituting 
ovarian apoplexy; or into one or more of the Graafian follicles, 
forming an ovarian hcematoma (Fig. 18). The lymphatics of the 



OOPHOKITIS 



63 



ovary may be chiefly involved, producing great oedema, softening, 
and enlargement, and constituting the condition known as (edema- 
tous ovaritis. The type of in- 
fection brought to the ovary by 
the lymphatics may be so viru- 
lent as to cause suppuration in 
the ovarian stroma, or ovarian 
abscess (Fig. 19). Sometimes 
there are a great number of pus 
foci, or there may be one large 
abscess. In certain cases no pus 
is produced but the inflamma- 
tion subsides, the Graafian folli- 
cles become distended, and ap- 
pear beneath the surface of the 

ovary as pearl-like bodies, forming the condition of cystic de- 
generation. Cystic ovaries are enlarged, or a portion of an 
ovary may be cystic and the rest shrunken. The production of 
connective tissue may be so great as to cause marked atrophy of 
the organ, it being converted into a mere mass of shriveled connect- 
ive tissue — sclerosis. The ovary may also be acutely inflamed in 




Fig. 18. — Hemorrhages into the Graaf- 
ian Follicles. 





Fig. 19. — Large Ovarian Abscess. 
It has been aspirated and its walls have collapsed. 

a curious association with contagious parotitis, and the organ ulti- 
mately become atrophied. Suppuration in the ovary is caused by 




64 GYNECOLOGY 

any of the pyogenic bacteria. Sometimes cystic accumulations 
become calcareous (Fig. 20). 

Symptoms. — In youth the ovary is pink and has a thin capsule. 
After hundreds of ovules have ruptured the organ becomes scarred 
and pale, the capsule is thickened, and the ovary distorted. No 
two ovaries are exactly alike, and there is a very great variety 
among perfectly normal ovaries. There is no standard of gross 
appearance to guide the surgeon in his 
operations upon the ovaries. Few symp- 
toms are produced by ovarian inflamma- 
tions which are not easily referable to 
associated diseases. 

Peri- oophoritis furnishes no distin- 
guishing symptom, as it is always accom- 
panied by some graver lesion, as salpingitis 
or pelvic peritonitis. 

Ovarian hematoma occurring suddenly 

Fig. 20.— "Stone in the may cause so rapid a distention of the ovary 

RY '" with severe pain located in one side as to 

Calcareous degeneration c l 0S ely simulate an ectopic gestation. Small- 

of the contents of an , . . „ 1 , -, . . , -. 

ovarian hematoma. er accumulations of blood in the ovary and 

cystic degeneration produce localized pain, 
which is increased a few days before menstruation — that is, at 
the time of ovulation. 

Atrophied ovaries produce no symptoms which are recognisable 
as due to that condition. 

Ovarian abscess cannot be differentiated from pyosalpinx. The 
history will presumptively indicate the character of the abscess. 
Ovarian abscess is most often found clue to sepsis after abortion 
or labour, and when due to gonorrhoea is commonly secondary to 
pyosalpinx. Upon examination there is felt to one side of the 
uterus or behind the broad ligament a dense adherent mass which 
is pedunculate, sensitive, and not fluctuating unless large. It is 
indistinguishable from a pyosalpinx, with which it is often asso- 
ciated. 

Usually there is fever, pain, etc., just as in pyosalpinx; but in 
certain old cases the pus becomes sterile, and no toxines being pro- 
duced, there may be no fever. The pus from ovarian abscess is 
notably virulent, owing to its being so frequently caused by strep- 
tococci. 



OOPHOKITIS 



65 



Treatment. — The treatment of peri-oophoritis is merely that 
of the accompanying peritonitis. The palliative treatment com- 
prises the application of 10 per cent ichthyol to the vaginal vault, 
saline purges, and perfect rest in heel. The operative treatment 
consists in freeing the organ from all false attachments by vaginal 
section, and draining the pelvis with iodoform gauze. 

Ovarian sclerosis is incurable by any means short of removal. 
But as the symptoms produced by such a condition are so 
little understood, sclerosed ovaries should never be removed 
unless the uterus also needs to be sacrificed. 

(Edematous oophoritis usually occurs under circumstances 
which require removal of the Fallopian tubes. Should it be 
found to exist alone — an exceedingly rare circumstance — the ova- 
ries are not to be removed, as involution is probable ; but the per- 
iphery of the ovary should be punctured in several places to reduce 
the swelling. 

Cystic Ovaries. — The condition being characterized by essential 
anatomical changes, medical treatment is without effect. Either 
through the posterior cul-de-sac or the abdomen the cysts, if few, 
should be punctured. If the cyst-bearing area is large that por- 
tion of the ovary is to be resected. If the entire organ seems dis- 
integrated and the degree of suf- 
fering is such as to warrant re- 
moval this must be done. 

Ovarian Hematoma (Fig. 18) . 
— This never calls for removal of 
the organ. The involved portion 
of the ovary is to be resected. 
If old, these blood cavities are 
lined by a distinct membrane. 
After incising the capsule of the 
cavity and carefully catching the 
escaping blood so as not to soil 
the peritonaeum, the lining is 
peeled out. The loose flaps left are trimmed before suturing is 
done. 

Ovarian abscess is treated in a manner similar to pyosalpinx, 
both as regards palliative and radical operations. 

Tubercular Ovaritis (Fig. 21). — This is never found as a pri- 
mary disease. It is always secondary, usually to tubercular peri- 
5 




Fig. 21. — Tubercular Ovaritis. 



66 GYNECOLOGY 

tonitis or salpingitis. It occurs as miliary infiltration or as 
cheesy deposits clue to the former. The disease may remain 
tubercular or the deposits may break down, producing ovarian 
abscess. The disease is more frequently limited to the peritonaeum 
of the organ. Finally, any lesion of the ovary, inflammatory or 
neoplastic, may become tubercular. 

Symptoms. — There are no symptoms to distinguish tubercular 
ovarian disease from any other infection of the organ except the 
chronicity of the disease, its painlessness, and slight rhythmical 
variations in temperature. 

Treatment. — The condition is always discovered accidentally 
during the performance of an intraperitoneal operation. It calls 
for the removal of the involved organ. 

Broad-Ligament Abscess. — Suppuration between the folds of 
the broad ligament was formerly much more common than now- 
adays. In the second 1,000 of my clinic cases I have seen but 6. 
The condition is due to a septic pelvic lymphangitis. The lym- 
phatics in the folds of the broad ligaments suppurate as a result 
of an infection coming from within a uterus which has recently 
been subjected to operation or abortion or labour ; or it may result 
from a broad-ligament haematocele which has sprung from a rup- 
tured ectopic gestation; or from a post-operative broad-ligament 
clot becoming infected. As a rule, the streptococcus pyogenes is 
the causative germ. As the pus forms it separates the folds of the 
broad ligament, the bulging being chiefly of the posterior layer, 
as the bladder in front prevents much distention anteriorly. As 
the abscess increases the peritonaeum is stripped from the poste- 
rior lower segment of the uterus, and it may lift the peritonaeum 
from the rectum. In front it may dissect the peritonaeum and 
bladder from the cervix, and in very large abscesses the peritonaeum 
may be lifted from the pelvic bones in front and be felt at Pou- 
part's ligament. If the lesion is bilateral the cavities may even 
connect in front of the cervix. The suppuration is essentially 
extraperitoneal. There is always more or less peritonitis present. 
It is suppuration in continuity of tissue, as distinguished from that 
in a preformed sac, like the Fallopian tube. As the abscess reaches 
a large size it is presented as a fluid accumulation lying on the pel- 
vic floor, pushing the uterus to one side, and above which lie the 
omentum and intestines usually adherent to the growth. Although 
the suppuration may be virulent, yet it is often found that the 



CELLULITIS 67 

ovaries and tubes are not involved. And, on the contrary, Fallo- 
pian and ovarian suppuration may coexist. 

Symptoms. — After an attack of pelvic inflammation, which is 
usually preceded by an abortion or labour, rigors and violent fluc- 
tuations in temperature may occur. Upon examination the uterus 
is found displaced, usually upward and to one side. It is sometimes 
lifted so high that the cervix cannot be felt. Extending from the 
side of the uterus to the lateral pelvic wall is a dense fluctuating 
mass immovably fixed to the uterus and presenting no sulcus be- 
tween the uterus and the mass; the growth is sessile upon the 
uterus. With large abscesses the rectum is partially obstructed 
and the bladder incapable of any considerable distention. L^pon 
opening the posterior cul-de-sac the finger will readily appreciate 
the bulging posterior wall of the broad ligament if the abscess be 
of moderate size; but if it has lifted the peritonaeum from the 
rectum the exploring finger will at once enter the abscess without 
penetrating the peritonaeum. 

Treatment. — If the abscess be small the attempt should be 
made to evacuate the pus from between the folds of the broad 
ligament by an incision under the abscess from the side of the 
cervix, so that the finger will not open the peritonaeum. The 
abscess cavity is then packed with iodoform gauze. But if the ab- 
scess be large the incision is to be made in the posterior cul-de-sac 
and the pus sought by means of the finger only. These cavities 
should not be irrigated lest the septic material be washed into the 
pelvic cavity through an opening accidentally made. When the 
abscess is very large it usually presents as an elevation just above 
Poupart/s ligament over which the skin is cedematous or glistening. 
It usually presents here before it raises the peritonaeum of the 
rectum and pelvic floor, and hence can easily be opened above 
Poupart's ligament by a strictly extraperitoneal incision. Such 
an abscess must be carefully washed out daily through double 
drainage-tubes. They close very rapidly. This condition calls for 
a radical operation only when bilateral tubal disease coexists, a 
condition not common with small broad-ligament abscesses. When 
tubal and ovarian suppuration is thought to coexist, the perito- 
naeum may be entered by the vagina and a careful examination 
made after the abscess is opened and its contents evacuated. In 
all cases where both the abscess and pelvic cavities have been en- 
tered, they must be drained by large quantities of gauze. Or an 



68 GYNECOLOGY 

abdominal section be performed, and if the abscess be broken into, 
either an abdominal or vaginal drain introduced. But laparotomy 
in cases of broad-ligament abscess gives a very high mortality. 

Diffuse Pelvic Suppuration. — Suppuration has occurred in 
tubes, ovaries, or broad ligaments, one or all, but has ceased to be 
confined to the original point of origin. The pus has escaped be- 
tween the adherent organs and has burrowed between the planes of 
plastic lymph which has been effused, or has broken through into 
the cavity of a hollow viscus. The condition is essentially of a 
chronic nature, and is not to be confounded with primary purulent 
peritonitis, which is always acute. The infection is usually of a 
mixed type. Cases thus afflicted are of the gravest nature. 

Symptoms. — The chronicity is marked. There is a history of 
weeks or months of suffering, recurrent chills, hectic, repeated 
acute exacerbations as the pus escapes into a new area of tissue; 
and usually the patient is bedridden. 

The uterus, ovaries, tubes, and pelvic cellular tissue are 
matted into a conglomerate mass in which with difficulty the 
organs can be distinguished from each other. The vaginal vault 
is dense and unyielding. The uterus is immovably fixed. Com- 
monly the posterior fornix bulges down into the vagina, and this 
swelling may fluctuate or be of fibroid hardness. The abdomen 
is permanently tympanitic. The bowels are very irregular in 
function, costiveness alternating with diarrhoea, and the bladder 
is incapable of fully contracting, being held by adhesions, hence 
cystitis is a common accompaniment. The temperature is steadily 
elevated, there being evening and morning fluctuations. Phthisis 
and nephritis are frequent complications, the latter rarely being 
absent. The rectum is canalized; it cannot contract. The patient 
suffers great pain not only in the special organs and abdomen, but 
also in hips and thighs from pressure on the nerves. The pus 
may escape into bowel, bladder, or vagina, or open above Poupart's 
ligament. There are dysmenorrhcea, menorrhagia, and often 
metrorrhagia present. Frequent douching is necessary to wash 
away the large quantities of yellowish or greenish pus that escape 
from the uterus. The tongue is dry, furred, and red. The appear- 
ance of the patient is that of one profoundly septic or of one 
suffering from typhoid fever. The pulse is rapid and feeble. 
Eepeated rigors are common. Death ensues from nephritis or 
pneumonia or sheer exhaustion. 



CELLULITIS 69 

Upon examination we find the absolute fixity of the uterus, a 
density anterior to the cervix not found except with broad-liga- 
ment abscess, fluctuating masses either posterior to the uterus or at 
the side, and a degree of involvement of the pelvic organs from 
which none seems to escape. 

The condition cannot always be distinguished from fibroid with 
suppuration. Leucocytosis is exaggerated, the haemoglobin re- 
duced, the spleen is not enlarged, and the blood does not give the 
Widal reaction, phenomena which will eliminate typhoid fever. 
The leucoc} T tosis as well as the history will suffice to differentiate 
the disease from pelvic hsematocele due to ruptured ectopic ges- 
tation. 

Treatment. — A cure is to be effected in the milder cases only 
by a radical operation. This may be done either by the abdomen 
or vagina, preferably the latter. But in the graver cases a radi- 
cal operation is positively contra-indicated owing to the danger. 
In these the surgeon should rapidly incise the posterior vaginal 
fornix and enter the pelvis with his finger. He should search for 
and empty all pus pockets. These are then packed with iodoform 
gauze. 

After the local and general condition has improved a radical 
operation may be performed. 



CHAPTEK III 
DISTORTIONS AND DISPLACEMENTS 

It is necessary to a proper understanding of pathological posi- 
tions of the uterus that the normal range of mobility of the organ 
be fully appreciated (Fig. 22). 

This is much more considerable than many admit. If the 
bladder becomes distended, as its enlargement proceeds the uterus 




Fig. 22. — The Normal Relations of the Pelvic Organs seen in Mesial Sagittal 

Section (Deaver). 



is not only forced backward but is lifted up (Fig. 23). This 
distention may be so great as to force the uterus against the 
70 



DISTORTIONS AND DISPLACEMENTS 



71 




sacrum; yet when the bladder is emptied the uterus will return 
to its normal position. In overdistention of the rectum the uterus 
is forced upward and forward (Fig. 24). When the woman is 
in a squatting position 
and straining down 
the uterus may be dis- 
placed downward but 
slightly in a normal 
pelvis. Under such 
effort the organ sinks 
a little lower and be- 
comes more antevert- 
ed. If retroflexed, this 
is exaggerated. 

The contents of the 
pelvis are semifluid 
and of nearly equal 
consistence. The pel- 
vis is closed below by 
the perineal muscles 
and its floor has but 
little mobility. Above, 
the abdominal muscles 
form a fairly rigid 
case for the abdom- 
inal viscera, and the 
diaphragm closes the 
cavity at the top. But 

the diaphragm is in continuous rhythmical movement in the act 
of breathing, and as it contracts it would increase the intra- 
abdominal pressure were it not for the fact that this pressure is 
kept uniform by the s}mchronous relaxation of the abdominal 
parietes. The intra-abdominal pressure is uniform under 

ORDINARY CIRCUMSTANCES. 

This pressure bears as well upon the under, anterior, and pos- 
terior surfaces of the uterus as upon the superior, and it is the 
knowledge of this equilibrium of semifluid contents in a closed 
cavity which explains the support of the uterus. The perimeum 
does not accomplish this other than it maintains closure of the 
bottom of the cavity. The ligaments play no part in maintain- 



FlG, 



23. — Forcible Distention of the Bladder dis- 
placing the Uteris Backward ( Tirogoff). 



n 



GYNECOLOGY 



ing the uterus in position until their uterine attachments are 
rendered tense by displacement of the uterus; they are opera- 
tive only when a certain degree of displacement occurs. When 
the pelvic floor is torn, the uterus tends to descend, not he- 
cause any support of the organ is severed, but because the equi- 
librium of the intra-abdominal pressure is disturbed and the 
pressure becomes greatest from above. Descent of the organ 
results. It will be noticed that antero-posterior section of the 
pelvis shows the vagina to be a mere slit with coapted walls. 

The rectum is open, 
filled with faeces or 
gas, but is practical- 
ly closed, for its end 
is held tightly shut 
by the sphincter ani. 
An explanation of 
why, when this 
sphincter is relaxed 
in defecation, the 
uterus does not de- 
scend is offered. The 
true pelvic diaphragm 
is the levator ani 
muscle. It surrounds 
the vagina and the 
rectum, being at- 
tached to the sphinc- 
ter ani of the latter. 
It may therefore be 
termed the opposing 
muscle of the sphinc- 
ter. Under the stim- 
ulus of the descend- 
ing column of fasces the levator ani contracts, and tends to 
pull apart the relaxed sphincter. At the same time it tightly 
closes the vagina. The rectum is filled with the faecal column, 
which lies posterior to and below the uterus. This column 
escapes in obedience to intestinal peristalsis and increased in- 
tra-abdominal pressure. The equilibrium of this pressure is 
not disturbed in the act of defecation, there being a perfect 




Fig. 24. — Forcible Distention of the Rectum displac- 
ing the Uterus Upward and Forward (Pirogoff). 



DISTORTIONS AND DISPLACEMENTS TS 

correlation in forces, and the position of the litems is not 
changed. 

But if the vagina is torn so that air enters it, or the tone of 
the abdominal muscles be damaged by overdistention, paralysis, 
or other cause, the equilibrium of the intra-abdominal pressure 
is disturbed, and the uterus must be supported by its anatomical 
attachments. As the levator ani constitutes the important part 
of the perineal body, and is torn when the perinaeum is ruptured, 
it cannot close the vaginal slit or pull apart the sphincter during 
defecation. As the column of faeces descends it meets the obstruc- 
tion of a partially closed sphincter, and the equilibrium of the 
intra-abdominal pressure is disturbed, in that the floor of the cav- 
ity is more relaxed than its sides and top. As a result the uterus 
sinks down, the faecal column pushes forward toward the unresist- 
ing vagina, rectocele is produced; and retroversion induced 
through traction on the posterior vaginal wall, together with the 
downward tendency of the intra-abdominal pressure. 

The behaviour of the uterus under the influences of posture is 
detailed in the article on Examination. 

Anteversion. — In childhood the uterus lies upon the bladder 
without either irritating the latter or embarrassing it in its func- 
tion. Pathological anteversion does not exist as a primary dis- 
ease. To be of degree sufficient to be called pathological it must 
be forced there by tumours. The symptoms and treatment of 
this displacement are those of the causative disease. 

Anteflexion. — This very common distortion of the uterus pre- 
sents several varieties with important distinctions. The exact angle 
of flexure which is pathological is not to be expressed in degrees. 
A rather sharp bend may in one patient be accompanied by no 
departure from the normal in either function or symptoms, while 
a less degree in another woman may be associated with sterility 
and a severe type of dysmenorrhea. This observation, together 
with many other disjointed facts, have convinced me that the 
flexure is but a greater or less prominent sign of a general dis- 
turbance in the uterus. Still, we are not prepared yet to change 
our exposition of the subject. There are two chief types of ante- 
flexion. 

Simple Anteflexion (Fig. 25). — The cervix occupies a rela- 
tively high position in the pelvis, owing to a rigidity and short- 
ening in the utero-sacral ligaments. The axis of the cervix is at 



74 



GYNECOLOGY 



the proper angle with that of the vagina, the cervix is not hyper- 
trophied, the external os is round, but the cervix otherwise nor- 
mal. The body of the uterus is sharply bent upon the cervix at 
or near the internal os. The point of flexure becomes changed, 
the anterior wall thickened, and the posterior much thinned. In 
some cases the body of the uterus is normal in size, in others it is 
much reduced. The endometrium becomes atrophic, and its lym- 
phoid tissue less abundantly supplied with cells. The cervix being 
fixed, as the woman stands the intra-abdominal pressure falls upon 

the posterior surface of 
the organ, and the flexure 
is increased. 

Symptoms. — These pa- 
tients are usually well- 
nourished. Menstruation 
is regular, occurring every 
four weeks. It lasts from 
one to four days, rarely 
longer, and is caught by 
from four to eight nap- 
kins. The flow is clotted. 
A few hours before notic- 
ing the flow a sense of 
weight in the pelvis comes 
on. This is speedily fol- 
lowed by pain in the ute- 
rus referred to a point just 
behind the pubis. This 
pain is intermittent and 
cramp-like or it may be 
continuous with spasmodic exacerbations. After the flow appears 
some relief is experienced. The flow gradually becomes watery 
and the pain decreases. Coincident with the pain is often a 
manifestation of hysteria. Some patients vomit, some have diar- 
rhoea, and occasionally hystero-epileptic seizures occur. After the 
flow ceases, a whitish, unirritating leucorrhcea supervenes and 
lasts a few days- 

Upon digital examination the cervix is found high in the pelvis. 
If the ringer is passed anterior to the cervix and between it and the 
bladder, the rounded form of the uterine body will be felt. 




Fig. 25. — Simple Anteflexion. 

The uterus is high in the pelvis, the cervix but lit- 
tle enlarged, and its axis in proper relation to 
that of the vagina, and the body of the uterus is 
sharply bent forward. 



ANTEFLEXION 75 

Viewed through the speculum, the external os is usually seen to 
be round, instead of being a normal slit. Occasionally, usually in 
anaemic women, a slight cervical folliculitis is present. The plug 
of mucus in the cervix is clear. If the sound is passed, an entirely 
unnecessary act, as a rule, it should be sharply curved, and not 
introduced until the cervix has been pulled down by bullet forceps, 
so as to straighten the uterus somewhat. At the internal os the 
sound will usually develop an exquisitely sensitive point. Vaginis- 
mus and dyspareunia are common results of this form of flexure. 

The cause of the dysmenorrhea is commonly attributed to the 
formation of clots within the uterus. This, I believe, is an error. 
In many cases of the most severe type which I have been com- 
pelled to treat during the menses, no clots have been found. The 
clotting occurs most often in the vagina. The blood clots because 
of the small amount of lymphoid elements contained in it. Nor- 
mally, for some days preceding menstruation, the endometrium 
becomes thickened owing to congestion. This is accompanied by 
an enormous multiplication in the lymphoid cells. These increase 
to such an extent that the epithelium is literally forced off the 
surface of the endometrium and from some of the glands, and 
blood and lymphoid elements are extruded. 

Softening of the endometrium due to the multiplication of 
lymphoid elements is the way in which menstruation normally ap- 
proaches; but in this form of flexure due to changes in the endo- 
metrium, few lymphoid elements are produced, the menstrual con- 
gestion has no relief in softening, and as a result pain is produced. 
It is the abnormal way in which the blood-pressure takes place 
which causes pain, and the blood clots because of scarcity of lym- 
phoid cells. 

Treatment. — These being my views, I seek to modify the life 
of the girl so that the dysmenorrhcea will not occur. 

Enough has been said regarding the influence of systemic 
changes upon the lymphoid endometrium to afford an explanation 
of the benefit which is often seen to follow a change of climate, etc., 
in these cases of anteflexion with dysmenorrhcea. Regulation of 
the diet will also tend to reduce the amount of pain accompanying 
menstruation. Many of these girls are plethoric, and have high 
arterial tension. In such cases it is my habit to put them on a 
dietary for ten days before an expected menstruation. They are 
denied all red meats, sweets, spiced food, and rich dishes. They 



76 GYNECOLOGY 

are given an abundance of fish, fowl, starches, fruit, and fresh 
vegetables. Each morning a light dose of aperient water, sufficient 
to produce one watery stool, is given. When the period occurs, they 
are made to lie down. If the cramps are so severe as to demand 
treatment, a capsule containing \ grain codeine and 3 grains phe- 
nacetine will relieve ; but the effect of the administration of 

AN OPIUM DERIVATIVE IN A PAINFUL AFFECTION OF REGULAR RE- 
CURRENCE must not be forgotten; a habit is too easily estab- 
lished. A far better preparation is the following: Ext. gelsemii 
fid. nx 3, with tr. hyoscyami TT| 30, if the nervous phenomena are 
marked, or with tr. cannabis Indie. 1U 20 instead of the hyoscyamus 
if the flow is increased. Upon taking any of these remedies the 
patient should lie down, with clothing loosened, and exciting com- 
pany prohibited. 

The dysmenorrhea may be rendered less by a dilatation of the 
cervix practised about a week before menstruation. 

But, inasmuch as the pain, sterility, and other symptoms are 
due more to the unnatural character of the endometrium than to 
the flexure, the indicated operative procedure is curettage with 
the sharp curette, thus removing the entire endometrium. In order 
that the new endometrium which forms after such a procedure may 
develop in the absence of circulatory stasis and cervical stenosis, the 
curettage is to be accompanied by bilateral incisions of the cervix 
and thorough dilatation of the cervical canal (Fig. 72). The 
various serious operations which seek to correct the flexure, such 
as laparotomy and resection of the posterior uterine wall at the 
seat of the bend, are to be condemned. The sole influence which 
can permanently so change one of these congenitally distorted 
uteri is pregnancy and labour at full term. But the bilateral 
incision, dilatation, and aseptic curettage will grant in many cases 
an immunity from severe dysmenorrhea. 

Anteflexion with Retroversion (Fig. 26). — This is the "ante- 
flexion with long conical cervix " of Marion Sims, or anteflexion 
with hypertrophy of the cervix as described by others. The uterus 
is low in the pelvis. The cervix is long and conical, the ante- 
rior wall being shorter than the posterior. The axis of the cer- 
vix is that of the vagina. The cervix is bent forward upon the 
body of the uterus and the latter is thrown backward somewhat, 
so that it occupies a plane posterior to the normal of some 
15 to 45 degrees. 



ANTEFLEXION 



77 



The cause of this peculiar condition is unknown. The cervical 
hypertrophy may be so great that the organ projects from the 
vulva, but the degree of flexure between cervix and corpus uteri is 
not changed by the amount of cervical hypertrophy. 

Symptoms. — The symptoms are similar to those of simple ante- 
flexion. Women possessing the form of anteflexion under discus- 
sion usually flow more and 
suffer less than those with 
simple anteflexion. Back- 
ache and pelvic tenesmus 
are more common than in 
simple anteflexion, and the 
ovaries have a tendency to 
become swollen and cystic, 
due to obstructed venous 
circulation in the broad 
ligaments. Leucorrhcea is 
present and more profuse 
than in the first class. There 
are no prominent differen- 
tial symptoms. Upon ex- 
amination the local condi- 
tion is most readily ascer- 
tained. The cervical hyper- 
trophy accompanying ante- 
flexion differs promilientlv "^he uterus * s l° w * n the pelvis ; the cervix is 

elongated, its two lips being unequally devel- 
oped ; the cervical axis is that of the vagina, 
and the body of the uterus occupies a plane 
posterior to that which is normal. The shaded 
portion shows the extent of the incisions in 
Sims's operation. 




Fig. 26. — Anteflexion with Ketro version. 



from infra-vaginal cervical 
hypertrophy in that there 
is a marked difference in 
the enlargement of the two 
lips of the cervix in ante- 
flexion. The speculum reveals the long conical cervix with its 
apex dimpled by the round external orifice. The sound will show 
that before it is turned to enter the cavity of the uterus it will 
pass through a cervical canal often 2 inches in length. 

Treatment. — The medical treatment of these cases is the same 
as that of simple anteflexion. The surgical treatment embraces 
two procedures — the operation of E. C. Dudley, and the author's 
modification of Sims's procedure. The indications to be filled by 
all operations are : removal of the hypertrophied cervix, removal 



78 GYNAECOLOGY 

of the diseased endometrium, and straightening of the cervical 
canal. If the cervical hypertrophy be less than an inch on the 
anterior lip, the modified Sims's operation will suffice to cure. 
But if the hypertrophy of the anterior lip be over 1J inch, Dud- 
ley's operation or conical amputation is preferable. 

Retroversion and Retroflexion. — The former designates a turn- 
ing backward of the uterus so that the cervical canal faces towards 
the anterior wall of the vagina, and the latter a backward flexure 
of the body of the uterus upon the cervix. Congenital backward 
displacements of the uterus are exceedingly rare, I having seen but 
3 instances in 4,000 clinic cases. These lesions are usually ac- 
quired. Any agent which causes a marked enlargement, or en- 
largement with softening of the uterus for some time, will conduce 
to a backward displacement. This is particularly true if at the 
same time the pelvic floor be torn. We see most of these cases 
occurring after abortion or labour. The next most frequent cause 
is infection of the uterus. Standing for hours during the men- 
strual days, particularly if associated with manual labour, will also 
produce it. It may occur acutely as the result of lifting heavy 
weights, or be produced by crushing in the abdomen as by a cart- 
wheel. The two conditions usually coexist in the same individual. 
A retrodisplacement of the uterus is any position of the uterus 
posterior to the normal, but does not always constitute a diseased 
state. As has been shown, overdistention of the bladder may 
force the uterus backward, yet this is not pathological retroversion. 
When the axis of the uterus is that of the vagina the displacement 
is that of the first degree ; when it is so far posterior as to be to 
the vaginal axis about 90 degrees, it constitutes the second degree, 
and all displacements below this are of the third degree. This 
classification is purely arbitrary, and is only used to facilitate de- 
scription. 

So soon as the uterus assumes the first degree, it is so placed 
that it bears the intra-abdominal pressure on its anterior face, and 
the tendency is for the displacement to increase. 

The retrodisplaced uterus is usually enlarged. The normal 
uterine secretion is retained because of the position of the organ, 
and is apt to undergo putrefactive changes, thus setting up an 
inflammation of the endometrium. The position of the uterus 
necessitates torsion of the broad ligaments, and as a result the 
venous plexuses become varicose, producing a form of chronic con- 






RETRODISPLACEMEXTS 79 

gestion of the uterus. The endometrium is thickened. The uterus 
may rest upon the rectum and cause an exfoliation of the rectal 
peritonaeum with slow formation of adhesions between the uterus 
and rectum. The lumen of the rectum is obstructed with resulting 
constipation and haemorrhoids. If the displacement is accompanied 
by salpingitis or peritonitis, the various adnexal lesions may be 
associated with the adherent displaced uterus. If the inflamed 
uterus and peritonaeum have formed high attachments to the bow- 
els, these will be displaced down into the pelvis as the retrodis- 
placement occurs. Very many cases of this displacement are due 
to the influence of uterine neoplasms. 

Symptoms. — My view is that not so much the displacement 
as the accompanying or causative lesions produce the symptoms. 
Backache is the most common symptom. It is exceedingly annoy- 
ing, is constant, often severe enough to make an invalid of the 
woman, and is referred to the sacral region. Pelvic tenesmus, or 
" bearing down, 7 ' is constant when the patient stands. There is 
often a dull aching pain in the region of each ovary due to vari- 
cose veins in the broad ligaments. This also induces a great 
weariness in the muscles of the legs, so that walking becomes 
most disagreeable. If the displacement be of more than the first 
degree, it drags on the bladder and produces irritability there. 
Dysmenorrhcea is common. As most of these cases are found in 
parous women in whom there is no cervical stenosis, the theory 
that obstruction to the menstrual flow produces the pain is un- 
tenable. Furthermore, the blood seldom clots in these cases. The 
menses are increased in amount and leucorrhcea is present. There 
are certain reflexes commonly present in these women. They are 
particularly irritable, and unreasonably so. They lose their self- 
control easily. A very characteristic occipital headache and pain 
in the nucha are very often present. As menstruation approaches, 
these two last symptoms increase until they often become unbear- 
able. The inability to take exercise induces anorexia and disturbed 
digestion. Hence, pallor, loss of weight, tympanites, etc., are pro- 
duced. The patient lies down a great deal, because in this position 
the pelvic congestion is lessened and the symptoms ameliorated. 
If the uterus be fixed in retrodisplacement it is very generally 
accompanied by some symptoms of adnexal disease, and the pa- 
tient will usually seek relief from these rather than from symptoms 
due to the displacement. 



80 



GYNECOLOGY 




Fig. 27. — Retroflexion and Retroversion of the Uterus. 
First Step in Bimanual Replacement. 



Upon examination, a relaxed and possibly torn pelvic floor is 
usually found. Vaginal examination shows the cervix facing down- 
ward in the vaginal axis, or forward. The finger passed anterior to 

the cervix fails to 
find the body of the 
uterus in its normal 
position, and upon 
passing the exam- 
ining finger behind 
the cervix it will 
appreciate the pres- 
ence of a body the 
shape of the uterus 
whose tissues are 
directly continuous 
with the cervix, 
and which moves 
with the cervix. 
The degree of sensitiveness is in proportion to the amount of 
metritis or adnexal disease present. Prolapse of the ovaries is very 
frequent, and they 
can be easily pal- 
pated low down 
behind the broad 
ligaments. 

Treatment. — 
Immediately upon 
finding a retrodis- 
placement its fixity 
or mobility must 
be determined, and 
the presence or 
absence of adnex- 
al disease proved. 
This is best done 

by attempting to replace the organ, 
the bimanual. 

In bimanual reposition the patient is in the lithotomy posture, 
with the hips elevated so as to relax the abdominal muscles. The 
clothing is loose (Fig. 27). One finger, or two, is introduced into 




Fig-. 28. — Second Step in Bimanual Replacement. 



The preferable method is 



RETRODISPLACEMENTS 



81 




Third Step in Bimanual Replacement. 



the vagina, and guides 
a bullet forceps which 
is hooked into the an- 
terior lip of the cer- 
vix. The cervix is 
drawn down and drags 
the fundus uteri away 
from the sacrum. The 
other hand is then 
crowded down on the 
abdomen until its fin- 
gers rest in the hol- 
low of the sacrum be- 
hind the fundus ( Fig. 
28). The vaginal 
finger now pushes the 
fundus up so that it 
lies well in front of 
the abdominal fingers 
(Fig. 29). When it is felt that these latter are well behind and 
somewhat beneath the fundus, the bullet forceps is removed and 

the vaginal finger 
is used to shove the 
cervix upward and 
backward as far as 
possible, while the 
abdominal hand 
pulls the fundus 
forward (Fig. 30). 
The final step is to 
lift the cervix up- 
ward and hold it 
- there while a pessa- 
ry or dressings are 
applied to the va- 
gina to prevent de- 
scent of the uterus. 
All procedures 
which are em- 

Fig. 30.— Last Step in Bimanual Replacement. PLOYED TO REPLACE 

6 




82 GYNECOLOGY 

THE RETROPOSED UTERUS MUST PROCEED IN ONE OF TWO WAYS: 
THEY EITHER SHOVE THE CERVIX HIGH AND BACK, OR ELSE PULL 
THE BODY OF THE UTERUS HIGH AND FORWARD. The bimanual 

method accomplishes the replacement by both acts. 

Some women are too stout, or have sensitive abdominal mus- 
cles, or have inflamed pelvic organs, so that this method is not 
feasible. It may then be tried under general narcosis ; or the uterus 
may be replaced in the knee-chest position by a knobbed repositor, 
or in Sims's position by means of an intra-uterine repositor. 

Replacement in the knee-chest posture is accomplished by lift- 
ing the perinasum with a speculum so that the vagina balloons 
with air. The repositor — a ball of cotton held in blunt dressing 
forceps — is then employed to lift the body of the uterus upward, 
and after it has passed the promontory of the sacrum, to push the 
cervix backward. This method is applicable in cases even when the 
uterus and adnexa are somewhat inflamed but the uterus movable. 

In replacing the uterus by Sims's instrument the patient lies re- 
laxed in Sims's position. The stem of the closed repositor is then 
introduced into the cervical canal, but not through the internal 
os, and the instrument is unlocked. The cervix is next shoved high 
and back towards the sacral promontory; the fundus falls forward 
if free, being dragged anteriorly by the empty bladder as the cer- 
vix proceeds backward. This is the easiest and simplest method of 
replacing the uterus, but necessitates intra-uterine instrumenta- 
tion, a thing to be avoided whenever endometritis or salpingitis 
exists; and is never without some risk owing to the very frequent 
presence of latent pyogenic cocci in the cervical canal. 

'Reposition by the sound is mentioned only to be unqualifiedly 
condemned as not only dangerous but as most unscientific and un- 
satisfactory. Occasionally a uterus will be encountered which is 
attached by an adhesion of greater or less length, or which is 
attached to a rectum having a long mesentery. In such a case 
the replacement will proceed to a certain point and then be checked ; 
or, if accomplished, the uterus will promptly assume the retro- 
posed position when released. 

It having been determined whether the uterus is retroposed 
and movable or belongs to the class of fixed retropositions, the 
method of treatment is to be decided upon. 

Movable Retroposition. — There are certain cases which have 
persisted for so long a time and the anterior vaginal wall has 



RETRODISPLACEMENTS 83 

shortened so much that while the uterus may be put into an ante- 
position, it is impossible to assemble the organs into their normal 
regional relations. Although such cases are movable, they are 
cured only by surgical procedures, and not always then. It is one's 
duty to carefully study each case, and, if possible, determine the 
cause of displacement and the sequence of the associated conditions. 
In the case of an uncomplicated retroposition which is readily 
replaced and in which no lacerations of the soft parts exist, a well- 
fitted pessary will relieve. The pessary is of no use, nay is posi- 
tively harmful, unless the uterus be first replaced. A pessary is 
selected of a width between the arms of the greater bow, a little 
greater than that of the vagina, and of a length equal to the distance 
between the cul-de-sac after the uterus is replaced and the internal 
urethral orifice. The preferable form is that of Albert Smith. 
The application of a pessary is an art not to be fully described. 
After introducing the pessary, the finger should be able to pass 
all around it, between it and the vaginal wall. The lesser bow 
should not protrude from the vagina. Xo painful pressure should 
be made upon any point, and in case pain is produced the patient 
should be taught how to remove the pessary. Once every other day 
a cleansing douche should be taken. The presence of a pessary is 
no bar to intercourse. In case a pessary does not fit a given case, 
it being too little curved or too wide, etc., its form may be changed 
by coating it with vaseline and running it through an alcohol flame. 
It is moulded then and held in proper shape while being cooled by 
water. After a patient has worn a pessary for a few months it may 
be taken out to see if the uterus will remain up without it. Should 
pregnancy supervene while a pessary is in, it should be removed 
as soon as the uterus becomes too large to fall back. A pessary 

SHOULD NEVER BE INTRODUCED WHERE ANY INFLAMMATION OF THE 
ADNEXA EXISTS OR THE UTERUS IS FIXED. 

Inasmuch as retrodisplacement occurring in the post-partum 
woman is apt to keep the uterus in a subinvoluted condition, re- 
placing the organ and keeping it up will conduce to involution. 
This is particularly true if the treatment is instituted before the 
tissue-changes become permanent — for instance, during the six 
months following delivery. But in all cases of retrodisplacement 
which are uncomplicated, and in which there is no laceration of the 
soft parts, or in which the lacerations have been repaired, a pes- 
sary is of great service. Too much emphasis cannot be laid upon 



84 GYNECOLOGY 

the importance of trying the pessary before resorting" "to any of the 
suspension operations. There is too great a tendency in the 

PROFESSION TO PERFORM OPERATIONS FOR RETRODISPLACEMENT 
WITHOUT EMPLOYING LESS SEVERE METHODS -FIRST. ' The pessary 

is introduced in the following manner : The left index finger is used 
not only to keep the cervix high and back after the uterus has 
been replaced by the bimanual method, but also to depress the 
perinasum. The well-lubricated pessary is grasped by the right 
forefinger in the lesser bow, and is held firmly by the thumb and 
middle finger. It is introduced sideways with the curve of the 
greater bow to the patient's left. As it passes the vulva the greater 
curve is directed up behind the cervix by the point of the left index 
finger. In doing this the pessary will be twisted so that its bilat- 
eral diameter will be transverse to the pelvis instead of antero- 
posterior as it was when introduced. When the greater bow is 
behind the cervix the lesser is tucked up behind the pubes by 
the finger. 

If the uterus has been replaced in the knee-chest or Sims's posi- 
tion the manoeuvres are but little different. A pessary should 

NEVER BE EMPLOYED WHERE THE DISPLACEMENT IS DUE TO ENDO- 
METRITIS UNTIL THE LATTER HAS BEEN CURED, NOR IN CONGENITAL 

cases. In certain very old cases of acquired retrodisplacement, 
when the anterior vaginal wall has shortened so much that the 
cervix cannot be shoved high and backward, the pessary should not 
be used. 

If the displacement is discovered during the puerperium, the 
uterus should be replaced bimanually and maintained in proper 
position by vaginal tamponade of sterile dressings. After the 
puerperium the pessary may be substituted for the dressings. It 
is most important that treatment be instituted as soon as pos- 
sible after the occurrence of the displacement. The article on 
subinvolution of the uterus may be consulted in connection with 
this phase of the subject. The surgical treatment of movable 
retrodisplacement embraces Alexander's operation, ventro-suspen- 
sion, ventro-fixation, anterior colpotomy, shortening the round 
ligaments, etc. In fact, the ingenuity of the surgeon is well shown 
in the great number of operations devised for this very common 
group of affections. As before said, none of these operations 
should be tried until all complicating lesions have been corrected 
and the pessary faithfully tried. 



EETRODISPLACEMEXTS 



85 



Adherent Retrodisplacement (Fig. 31). — The uterus may in 
early life become retroverted or retroflexed, and a low form of 
plastic peritonitis follow which will bind it to the rectum. In such 
a case the ovaries and tubes are not inflamed. Or, as a result of 
a mild degree of septic peritonitis, the uterus may be fixed in a 
retroposed position and the adnexa be uninvolved. But, as a rule, 
although adnexal lesions cannot be discovered upon examination, 
by far the greater number of fixed retropositions are accompanied 
by a greater or less degree of adnexal disease. Therefore the dis- 
placement becomes of secondary consideration. In these cases the 




Fig. 



iEXT RETROVERSION. 



pessary, Alexander's operation, etc., become of no avail until the 
uterus is rendered movable. Fixed retroposition of the uterus 

ALWAYS CALLS FOR AN INTRAPERITONEAL OPERATION. The adlie- 

sions should never be severed by forcible bimanual massage (the 
methods of Sims and Schultze), for it is impossible to accurately 
measure the degree of adnexal disease which complicates the retro- 
displacement or to correct such complication if it exists, unless the 
peritoneal cavity be opened. The author's preference is for the 
posterior vaginal section in most of these cases, or the abdominal 
section and ventro-suspension. The operations of Mann, Wylie, 
Palmer Dudley, and the author's hystero-cystorrhaphy may be per- 
formed after the abdomen has been opened and the uterus freed. 
The operations which are advised will be described later. If preg- 
nancy occurs, it will progress up to the point where the uterus 
ceases to rise owing to the fixity, and abortion will ensue. 

If repeated pregnancies occur, the uterus will abort very nearly 
at the same period of gestation in each. 



86 



GYNECOLOGY 





PROLAPSUS 

This may be of any degree, from that slight descent which so 
often accompanies retroversion to complete escape of the organ 
from the body. It cannot therefore be measured in degrees. It 
usually occurs in women who have had children, occasionally in 
the nulliparous. There are essential differences in the two types. 
As a rule, the displacement is of gradual formation, but may 
occur as the result of sudden effort or violence. 

Complete Prolapse in the Parous Woman (Fig. 32). — The va- 
gina is completely inverted. The tumour hangs from the pubes 

through the insertion there 
of the bladder, from the 
vaginal attachments to the 
sphincter ani and pelvic fas- 
cia, and from the uterine 
ligaments. In the present- 
ing mass are the uterus and 
bladder with the ovaries and 
tubes lying above. The con- 
tents of the sac are often, in 
old cases, bound together by 
plastic lymph, making the 
tumour irreducible. The 
squamous vaginal epitheli- 
um is thickened and scaly. 
Near the cervical orifice the 
moisture, together with fric- 
tion on the thighs, may pro- 
duce ulcerations. The ute- 
rus is engorged from stasis. 
If the cervix is torn, its lips 
are widely separated. The uterus is in a condition of metritis, 
and hypertrophic endometritis is present. There is retention of 
urine in the prolapsed bladder, and cystitis occurs. Tension on 
the broad ligaments produces pressure on the ureters, and hydro- 
nephrosis may result. (Edema of the mass or inflammation may 
produce such stasis that sloughing is threatened, or the uterus 
may become pregnant while prolapsed and become strangulated. 
The condition is essentially a hernia, and, like inguinal hernia, 




Fig. 32. — Complete Prolapse of the Uterus 



PROLAPSE 87 

is liable to the complications of impaction, strangulation, and 
irreducibility. 

Prolapse of the uterus usually starts from a break in the pelvic 
floor which disturbs the equilibrium of the intra-abdominal pres- 
sure so that the supporting force is less than that operating from 
above. As a rule the prolapse proper begins first at the cervix, 
but this has been preceded by the formation of a cystocele, some- 
times a rectocele which induces retroversion. Then the true pro- 
lapse begins. Attention is again called to page 71, where the 
mechanism of the pelvic floor is dealt with. The prolapse may 
begin at the vulva first, the vaginal tube turning inside out at this 
point and the uterus coming down in practically an unchanged 
relation to the vagina. Thus, we occasionally see the anteflexed 
uterus or anteverted uterus as well as one retroposed come out of 
the body in that position in which it lay when the prolapse 
began. We may therefore find the uterus lying in almost any 
shape and position in the prolapsed sac. After a prolapse has 
lasted a long time, all parts of the uterus become atrophied in 
many instances, and the same shrinkage takes place in the ad- 
nexa. As a result, the prolapsed sac will contain the bladder 
and an elongated dense cord of fibrous tissue which represents 
the uterus. 

Symptoms. — When the prolapse occurs acutely it will be ac- 
companied by rupture of the supporting ligaments of the uterus 
with great shock due to haemorrhage and severe pelvic pain. For- 
tunately, the accident is extremely rare. In chronic prolapse, as 
the displacement progresses we have the same symptoms as were' 
said to follow retroversion, but intensified. The interference with 
the functions of bladder and rectum is particularly marked, and 
these patients have frequently to hold the mass within the body 
during the acts of defecation and urination. But in some cases of 
long standing, particularly in women who have passed the meno- 
pause, there may be no symptoms whatever other than those due to 
the inconvenience of a mass between the thighs, and impaired blad- 
der and bowel function. If ulcerations are present, they produce a 
purulent discharge. Since the lesion is found about the menopause 
as often as earlier, the menses are decreased as frequently as other- 
wise. Although these uteri are exposed to much handling and 
filth, purulent endometritis is infrequent, owing to the free escape 
of discharges and the perfect drainage. 



88 GYNECOLOGY 

Upon examination will be found an oval tumour whose apex is 
below and which is somewhat constricted at the vulva. The cer- 
vical opening will be found at the apex ; the covering of the tumour 
is skin-like and the attachments of the tumour are at the vulva. 
The finger passed into the rectum will occasionally pass down the 
posterior wall, and a sound in the bladder down the anterior. The 
uterus may be probed and the direction of its canal shown. Ulcera- 
tions may be seen at almost any part of the mass, but are most 
frequent about the cervix. The urine is usually ammoniacal in 
odour, the bowels costive, and the general health greatly impaired 
because of inactivity. 

As a rule, the mass is easily reduced but readily recurs. When 
peritonitis has occurred the organs may be so matted together as to 
be incapable of reduction, although replacement en masse be pos- 
sible. In lesser degrees of prolapse, before the uterus has escaped 
out of the body, the tendency to do so will be shown by caus- 
ing the patient to bear down hard as she lies on her back, 
and the cystocele and rectocele will be seen to roll out and the 
uterus to descend. The diagnosis is exceedingly easy, and only- 
gross carelessness can confound this condition with polypus, in- 
version, and infravaginal hypertrophy of the cervix. The prog- 
nosis is generally good. The symptoms are relieved by palliative 
treatment, and the various operations succeed more often than 
they fail. 

Treatment. — The attending physician should first determine 
whether the hernia can be reduced. Mechanical supports should 
be tried in all instances even though it is intended to operate 
later; for if retentive operations are performed in a case of long 
standing the sutures must hold the organs within a cavity which 
has long become accustomed to their absence, and against an intra- 
abdominal pressure unaccustomed to their presence. Should 
ulcerations be present, these must be healed by supporting the 
uterus with dressings of low percentages of iodoform, frequently 
changed and held in place by a T-bandage. The best mechanical 
support is furnished by an air-filled rubber ball. A ball should 
be selected which can just be made to pass the introitus vagince 
after the uterus is returned. It is to be removed after the patie'nt 
retires at night, and reintroduced before rising in the morning. 
If the patient is stout and has difficulty in replacing the uterus 
while lying on the back, she may assume the knee-chest posture. 



PROLAPSE 89 

Next to this in usefulness is the cup pessary supported by a waist- 
belt and suspensory straps. If the patient is old or very feeble, or 
if for any reason prolonged narcosis and protracted detention in 
bed would be dangerous, and if mechanical devices do not furnish 
sufficient relief, the uterus should be removed by the vagina and 
the stumps fastened to the vault of the vagina. If the patient is 
in the childbearing period of life and sufficiently strong, an attempt 
should be made to cure the deformity by operations. Curettage 
of the uterus should be the first step in all cases where the uterus 
is large, as it assists in producing involution. The next step is to 
amputate the cervix in such a way as to fold in the vault of the 
vagina, by an amplification of the operation described on page 
197. This will cause such a narrowing of the pericervical ring of 
connective tissue that the uterus cannot descend through it. A 
very close and high colpoperinaeorrhaphy should be performed, and 
in such a way as almost to close the vagina. All these operations 
can be done at one sitting. But, as has been said, enfeebled old 
women were better treated by vaginal hysterectomy, for they easily 
succumb to complications if kept long in bed, and their atrophied 
tissues furnish but poor support for plastic work. 

By some it is thought that complete prolapse is not dangerous, 
but only inconvenient. This is far from the truth, for cystitis, ure- 
teritis, and pyelitis can occur in women who carry residual urine 
in their bladders more readily than in old men, for in women infec- 
tion is more easily contracted through the short urethra. It has 
not been shown that malignancy is more prone to occur in uteri 
prolapsed than in others. While the series of operations men- 
tioned are usually sufficient to retain the uterus, yet if the vagina 
be very voluminous around the cervix it may be narrowed just in 
front of the cervix on the anterior wall by an oval denudation — 
anterior colporrhaphy. 

Complete Prolapse in the Nulliparous. — In such cases the uterus 
is forced out of the body either by pressure of a superimposed 
tumour or because of great weight in the uterus itself from a 
uterine fibroid. Added to the symptoms of prolapse are those of 
the causative neoplasm. Such cases call for abdominal section and 
removal of the uterus, if it be the seat of a fibroid. If the dis- 
placement is caused by an adnexal tumour this should be removed, 
hysterorrhaphy performed, and a close posterior colporrhaphy done. 
Mechanical supports in these cases are useless. 



90 GYNAECOLOGY 

Partial Prolapse. — The pathology and causation of this condi- 
tion are the same as in complete prolapse, only the lesions are not 
as extensive. The nterns comes down in the vaginal axis preceded 
by a large cystocele. There are present the same pelvic tenesmus, 
dragging pains in the pelvis, backache, etc., as in retroversion and 
complete prolapse. The uterus not yet having escaped from the 
vulva, mechanical supports are not indicated, and if employed will 
prove inadequate. The uterus should be curetted, the cervix ampu- 
tated, colpoperinseorrhaphy performed, and possibly anterior col- 
porrhaphy. It is well to do all the operations at one sitting, 
except the colpoperinseorrhaphy, which should be postponed until 
the anterior colporrhaphy has healed well ; for it is not wise to 

HAVE AN ANTERIOR SET OF SUTURES PULLING AGAINST A POSTERIOR 
IN A CASE WHERE THE TENSION ON EACH SET OF SUTURES MUST BE 

as much as the tissues will stand. But where a close colpo- 
perinaaorrhaphy will suffice to hold up the cystocele, anterior col- 
porrhaphy may not be needed. 

Inversion of the Uterus (Fig. 33). — The uterus is turned inside 
out. Childbearing and fibroid tumours are the most common 
causes. The condition is very infrequent. It starts in a depression 
at the fundus, and may be of any degree from this to that of a 
complete inversion. The hollow in the inversion is occupied by 
the tubes, often the ovaries, and sometimes intestinal coils. The 
accident may occur immediately after labour, or come on gradually 
some days later. If due to fibroids it comes on gradually. 

Symptoms. — As soon as the inversion occurs, an alarming 
haemorrhage takes place, rapidly producing a profound shock. The 
reflex symptoms are vomiting and great uneasiness of mind. Upon 
examining the case immediately after the occurrence of the acci- 
dent, the mass will commonly be found protruding from the vulva ; 
but if seen after some days, the shrinkage in the uterus may allow 
its recession within the vagina. The tumour is deep red in colour, 
pear-shaped, with apex at the vulva, soft, and bleeding easily, and 
at the base may be seen the two Fallopian orifices. The tumour 
can always be partially reduced, and its pedicle is of general circu- 
lar attachment rather than at one point. These two last points 
are of especial value in eliminating the possibility of the tumour 
being a polypus. Eectal examination will find the depression above 
the attachment of the pedicle, and show the absence of the uterus 
from its normal position. 



INVERSION 91 

The mortality attending the condition is very high and rather 
sudden, often within a half hour after the occurrence of the acci- 
dent. Death is due to haemorrhage. 

In rare instances the uterus will become spontaneously reduced, 
but usually taxis or operation alone will relieve. 

Treatment. — Taxis. — The sooner attempted the better. Con- 
tinuous and firm pressure should be made upward by the hand 
which grasps the entire organ in such a way as to push it upward, 
while the other hand attempts dilatation above of the inversion 




Fig. 33. — Inversion of the Uterus. 

ring. Most cases are readily relieved in this way. Chloroform 
narcosis is of assistance. The reduction should not be attempted 
by pushing up on the fundus alone. It is wise to pack the uterus 
with weak iodoform gauze after reduction and administer ergot. 
If taxis fails an operation is necessary. The preferable procedure 
is to tilt the uterus as high upward as possible so as to expose 
the posterior cervico-vaginal junction. This is then seized by bullet 
forceps and pulled down. The operator next, and with great cau- 
tion, incises the posterior lip of the cervix through all its thick- 
ness. In doing this the posterior cul-de-sac may be opened — a 
matter of no concern. The two lips of the incised cervix are now 



92 GYNECOLOGY 

grasped by bullet forceps and steadied while reduction by taxis 
is done. After replacing the mass, the rent in the cervix is sewed 
up and the uterus packed with iodoform gauze. If the cul-de-sac 
has been opened it is better to drain this, for these cases have 
usually been subjected to much handling, and peritoneal infection 
is easy. 

The uterus may occupy other and unusual positions in the pel- 
vis and assume other shapes. It may be lateroverted or latero- 
flexed; but such alterations in position and form are usually 
caused by the pressure of neoplasms or traction by adhesions. The 
causative lesions rather than the position of the uterus demand 
treatment. 

LACERATIONS OF THE CERVIX 

The cervix uteri may be torn in any direction during labour, 
particularly if this be accompanied by the use of instruments. 
But, as a rule, the tears are lateral. The left side of the cervix is 
more often torn, next in frequency the right side, and bilateral 
tears are least frequent. The tear may be straight, or forked and 
stellate. The tear is always limited to the vaginal portion of the 
cervix. Tears above this would be ruptures of the lower segment 
of the uterus. The torn cervix may evert, exposing the cervical 
mucosa to irritation and infection, thus conducing to cervical fol- 
liculitis and carcinoma. If the tear is bilateral and deep, it will 
permit the uterus to sink down and produce reduplication or inver- 
sion of the upper portion of the vagina. As a result, the uterus 
assumes a position in the pelvis lower than normal, and becomes 
engorged and enlarged. Torn cervices are particularly prone to 
become cystic, and be thus much increased in size. The low posi- 
tion, the engorgement and cystic degeneration of the torn cervix, 
make it easy for the epithelium to be rubbed off, thus producing 
erosions. The enlargement of the cervix, of the uterine body, 
and descent of the organ as a whole, produce engorgement of the 
veins of the broad ligaments. This chronic vascular stasis leads 
to the production of connective tissue in the corpus as well as in 
the cervix and to hypertrophy of the endometrium. The passage 
of the sound will even in the worst cases show that the internal 
os is normal in size or even contracted. Laceration of the cervix is 
a frequent cause of subinvolution and chronic metritis. 

It is necessary to describe a normal cervix in order to deter- 



LACERATION OF THE CEKVIX 



93 




Fig. 34 



The Normal Virgin Cervix 
(Berry Hart). 
c, the posterior lip of the cervix. 



mine what is abnormal, and in doing so I nmst digress a little (Fig. 
34) . Nature has provided the woman with a menstrual function at 
the age of thirteen, and with powers of procreation a year or so 
later. It is interesting to note that at this age there is scarcely any 
recognisable vaginal portion to the cervix, and that the external os 
is a bilateral slit about J of an inch in diameter. The girl is ana- 
tomically perfect and physiologically active. Nature intended her 
to propagate her species at this 
time, and if she did so her la- 
bours would be easy and injury 
to the cervix unlikely. But civ- 
ilization has decreed that the ex- 
ercise of this greatest of all phys- 
ical gifts shall be postponed un- 
til certain accomplishments have 
been acquired, and in the highest 
walks of life to about the twenty- 
fifth year. During all these years 
of waiting certain subtle changes 
have been going on in the cervix, 
as well as in the body of the uterus, the chief characteristic of 
which is an increase in the vaginal portion. Not in all cases, but 
in many. Such a woman coming to her first child-bed will suffer 
an injury to this distorted cervix. It is my observation that first 
labours, even in women with true anteflexion in whom there is no 
cervical hypertrophy, rarely produce cervical laceration. 

The laceration, then, is usually a tear in a cervix 
already abnormal. 

Symptoms. — The mere separation of the cervical lips produces 
no symptoms. The ill effects accompanying laceration of the cer- 
vix are due either to lesions which precede the injury or follow as 
sequelae. If the tear be extensive it may at once produce a haemor- 
rhage so severe as to demand treatment. Post-partum haemor- 
rhage, if accompanied by a contracted uterus, is generally due to 
laceration of the cervix. Upon exposing the cervix the spouting 
vessel will be seen opening upon the torn surface. 

In view of the effect which wide laceration of the cervix has 
upon the position and size of the uterus and upon the pelvic circu- 
lation, as well as upon the cervix itself, we find that menorrhagia 
due to uterine and endometrial engorgement is common • that leu- 



94 GYNECOLOGY 

corrhcea, both white and purulent, due to cervical folliculitis, are 
present ; that nervous phenomena due to cystic cervix are seen, and 
that backache, pelvic tenesmus, hysteria, pain in the nucha, etc., 
are often symptoms. These symptoms are not due to the mere 
separation in the fibres of the cervix, but to sequelae. 

The " cicatricial plug," which at one time was even thought to 
cause optic neuralgia as well as other reflexes, has disappeared in 
the light of more precise pathology. It is claimed by some that 
the too open cervix conduces to sterility and to abortion. I doubt 
this. If these conditions exist they are rather due to complica- 
tions. Sterility is due to a very commonly present endometritis, 
for the cervix has nothing immediate to do with procreation among 
mammalia. Most animals have no vaginal cervices at all and yet 
procreate; and those which have also sustain lacerations as do 
women, and do not suffer from sterility. Abortion can hardly be 
directly due to tears in the vaginal cervix, because the cervical canal 
at the internal os is more closed than normal, and what abortions 
occur are not in the later months when the internal os is part of 
the uterine cavity, but in the early months when the internal os is 
closed. Abortions are due to accompanying lesions, usually inflam- 
matory, such as adhesions. 

I am a firm believer in the influence of abnormal cervices, par- 
ticularly if torn badly, as causes of epithelioma of the cervix. 

Treatment.—*- -In a case of post-partum haemorrhage the source 
of the bleeding being a tear in the cervix, this should be immedi- 
ately sewed up. Not only will such closure of the rent stop the 
bleeding, but it will also conduce to a more rapid involution. The 
operation does not require narcosis and is painless. 

The proper manner of treating a laceration of the cervix will 
depend largely upon the coincident complications. No operative 
procedure should be applied to the cervix if there be inflammatory 
disease of the tubes or ovaries. Nor should a plastic operation be 
done upon the cervix if infection of the cervical glands or of the 
endometrium is present. Bacteriological examination of the uter- 
ine discharges will aid in determining this. It is wise to cure all 
erosions of the cervix and to relieve engorgement by a few days' ap- 
propriate treatment before proceeding to operate upon a torn cervix. 

There are two operations applicable to the condition under 
discussion : trachelorrhaphy and amputation of the cervix. Trache- 
lorrhaphy is indicated in all lacerations provided there is no hy- 



LACEKATION OF THE PEKIN^EUM 95 

pertrophy of the cervix and no cystic degeneration, and no marked 
hypertrophy of the cervical mucous membrane. How rare such an 
exception is may be inferred from what I have said. The opera- 
tion is much abused, owing to a mistaken conception of what is 
normal and what abnormal. The mere separation of tissues in the 
vaginal cervix does not call for operation. If there be hypertrophy 
of the cervix, or marked and general cystic degeneration of the 
Nabothian follicles, or hypertrophy of the cervical glands, amputa- 
tion of the cervix is indicated. And as most torn cervices present 
some of these lesions, amputation and not trachelorrhaphy is gen- 
erally indicated when any operative procedure is demanded for 
laceration of the cervix. 



LACERATION OF THE PERINEUM 

A laceration of the perinaeum which does not cause separation 
of the fibres in the sphincter ani muscle is " incomplete " ; one 
which extends through the sphincter is " complete." 

The injury appears in two forms : as a recent or as an old 
injury. The muscles of the perinaeum together with their fascial 
sheaths form a musculo-fascial diaphragm which closes the pelvic 
outlet. This diaphragm is perforated by the vagina and the rectum. 
In an uninjured condition and state of normal muscular tone there 
is no break in the pelvic floor, and the latter furnishes a perfect 
inferior support to the pelvic contents and thus helps to maintain 
the intra-abdominal pressure in equilibrium. The chief factors 
in the integrity of the pelvic diaphragm are the sphincter and 
levator ani muscles with their sheaths. So long as the normal mus- 
cular and physiological tone of these structures are present there 
is no break in the pelvic support of the intra-abdominal pressure, 
even in the act of defecation. 

When an incomplete laceration of the perinasum occurs, the 
vaginal skin is usually, not always, torn, the fibres of the levator 
ani muscle more or less torn, and the point of attachment of the 
bnlbo-cavernosus muscle to the transversus perinei severed, together 
with laceration of the fascial sheaths of these muscles. After the tear 
takes place the separated muscular and fascial fibres retract towards 
their points of fixed attachment. As a result, the viscera which 
were retained within the pelvis have a tendency to protrude be- 
tween the torn structures, and the conditions of a true hernia are 



96 



GYNECOLOGY 



presented. Separation between the fibres of the muscles and fascia 
are usually accompanied by a tear in the vaginal skin also, but it 
must be remembered that the laceration of the muscle and fascia 
may take place beneath the vagina, and without laceration of 
the latter. The lacerations are usually to one side of the median 
line, rarely in the centre. They are commonly upon the right 
side. After the tear takes place, the fibres of the levator ani 
and its fascia retract towards the " white line " of the pelvis 
(Figs. 35 and 36). As viewed from below, this retraction pro- 
ceeds upward and 
outward, and upon 
each side we notice 
a sulcus or angle of 
depression on the 
posterior vaginal 
wall between which 
is more or less of 
a protrusion of the 
rectal wall. It is 
essential that the 
direction of retrac- 
tion of the torn 
muscular and fas- 
cial fibres be borne 
in mind in order 
that the manner 
of approximating 
them by operation 
may be understood. 
The longer the in- 
jury has lasted the 
greater the retrac- 
tion. Absorption 
of the pelvic fat 
and general emaci- 
ation will add very 
materially to the 
extent of the separation. Anatomically the upper fibres of the 
supporting fascia lie but a little distance below the cervix. This 
is called the crest of the perinamm. It does not tear unless the 




Fig. 35. — Cystocele and Rectocele. 
Opposite the lower fingers of the examiner's hands the 
"angles" are seen. Beneath these are the retracted 
fibres of the levator ani muscle and facia. 



LACEKATION OF THE PEKIX^EUM 97 

lower fibres are torn, but in normal labours merely stretches. This 
higher attachment of the pelvic fascia and levator ani muscle is 
what supports the anterior vaginal wall, and it is this which forms 
the lower border of that somewhat open space about the cervix 
which we call the vaginal cul-de-sac. 

From what has been written, it will be seen that I consider the 
most important part of the pelvic floor to be above the orifice and 
above what is called the perinseum proper. When an incomplete 
tear occurs, the higher muscular and fascial fibres retract towards 
the two " white lines/' while the vulval portion is drawn by the 
sphincter ani backward (Fig. 36) . So there is furnished facility for 
prolapse of the higher pelvic organs, the uterus and bladder, and 
for the lower, the rectum and urethra. One result of the laceration 
of the levator ani is removal of the muscular opposition to the 
sphincter. As a result, active dilatation of the sphincter is impos- 
sible, and faeces are forced out only by increased effort of the ab- 
dominal muscles. Under this straining the faeces come down to 
a sphincter which is but partially open, and as a result the rectum 
bulges out between the " angles " of the vagina and presents as a 
hernial protrusion or rectocele (see Fig. 35). Prolapse of the an- 
terior vaginal wall follows later, and merely because its higher and 
lower supports are gone. When the anterior wall comes down it 
drags with it the bladder, forming a cystocele. If the urethra 
drops it is usually due to a coincident injury to its supporting liga- 
ments. As the anterior and posterior vaginal walls descend they 
drag down the uterus somewhat; but it is more the continuous 
straining at stool in these cases, with lack of equilibrium in the 
intra-abdominal pressure, which conduces to retroversion and de- 
scent of the uterus. The mere loss of equilibrium, unaccompanied 
by increase in the pressure from above, is not so potent a factor in 
producing retroversion and prolapse, for we notice that in com- 
plete LACERATION", WHERE THE SPHINCTER IS TORN, F.ECES ESCAPE 
WITHOUT PRESSURE, AND DESCENT OF THE UTERUS IS NOT OFTEN 

seen. As less important results of the tear in the perinaeum are 
loss of semen after coition, the entrance and escape of air from 
the vagina with an embarrassing noise, constipation with impaired 
digestion, muscular weakness and general malaise, retained urine 
in a cystocele pouch and cystitis, and chronic invalidism. 

When first made, a perineal tear presents as a triangular raw 
surface to one side of the median line, bleeding freely but with 
7 



98 



GYNECOLOGY 



little tendency to separation between the lips of the tear, livid 
in hue, and with cedematous edges. The tendency in this injury 
for the torn edges to remain in apposition conduces to sponta- 
neous healing. Beyond a slight haemorrhage, there are no imme- 




diate results of incomplete rupture of the perinaeum. In view of 
the remote results, however, the wound should at once be closed. 
When the tear is complete, the sphincter ani muscle straightens out 
and recedes towards the coccyx (Fig. 37) . And as time passes what 
was once a circular muscle becomes but a bundle of shortened and 



LACEKATION OF THE PEED^EUM 



99 



crescentic muscular fibres which have lost their ability to stretch. 
There is a tendency to prolapse of the rectal wall, and opposite the 
receded ends of the torn sphincter will be found a dimple, above 
which are usually several nodular protrusions of rectal mucosa. 
There is little tendency to the formation of a rectocele or a retro- 




Fig. 37. — Rupture of the Recto-vaginal Sjsptum, originally extending high up 
along the Posterior Vaginal Wall, but now pulled down by the Con- 
tractions of the Sphincter into a Shallow Arc with Extreme Separation 
of the Sphincter Ends (Kelly). 



version, but the bladder and urethra tend to drop. The vaginal 
saeptum is commonly torn for a greater or less distance, but rarely 
higher than the innermost fibres of the sphincter. Faeces and intes- 
tinal gases escape without control, keeping the patient soiled and 
irritated, except when most costive. Whereas laceration of the 
perinseum is usually upon one side, when the rent severs the 
sphincter this is usually in the median line. 



CHAPTEE IV 
DISEASES OF THE VULVA 

Vulvo-vaginal Cyst (Fig. 7). — The duct of the vulvo-vaginal 
gland may become closed at any point owing to adhesive inflamma- 
tion. The retained fluid secretion will then accumulate in the 
duct and make a cyst of the duct; or the gland itself may become 
distended, forming a true glandular cyst. These are "cysts of re- 
tention/' little or no alteration taking place in their contents, which 
are viscid and clear, or turbid from admixture of epithelium. 
They are generally due to gonorrhoea. 

Symptoms. — The cyst forms slowly and without irritation. 
After a time the patient notices an enlargement during her toilet. 
The cyst lies low down on one side near the posterior commissure. 
It is to be differentiated from abscess in the same location, from 
hernia, cysts of the round ligament and hydrocele; but the cysts 
of the vulvo-vaginal gland occupy a much lower position than any 
of these except abscess. The cyst is little sensitive upon, pres- 
sure; its contents are found to be fluid and the sac moves freely 
underneath the skin, signs which are absent in abscess. 

Treatment. — The cyst may be either incised and the cavity made 
to heal by granulation with iodoform-gauze drains, or preferably 
it is to be radically removed. 

An incision is made along the cutaneous border of the enlarge- 
ment down to the cyst. A careful dissection is then begun which 
proceeds from below upward and in such a manner as to avoid 
rupturing the cyst or breaking through the thin mucous membrane 
on its inner side. The nutrient artery lies at the upper side and 
should be firmly secured. All other vessels are tied to prevent for- 
mation of a hasmatoma, the cavity carefully cleansed, and the edges 
of the wound closed. 

Elephantiasis. — This is a pachydermatous enlargement of the 
clitoris, the labia, or the nymphae, due to connective-tissue hyper- 
100 



DISEASES OF THE VULVA 101 

plasia and obstruction of the lymphatics. It is not uncommon 
in the negress. It is usually unilateral if the labia are the in- 
volved organs. There is frequently a syphilitic history. Lack of 
cleanliness produces superficial ulcerations. 

Symptoms. — A dragging pain in the lower pelvis, difficult uri- 
nation, dyspareunia, foul discharge if ulceration is present, and 
the odour of genitals which cannot be cleansed, are the common 
symptoms. 

Treatment. — The mass should be excised. The vessels are so 
large that haemostasis should proceed with the incision. It is not 
wise to depend upon sutures to control the bleeding; and in draw- 
ing down the mass so as to form a pedicle cut vessels may snap 
back out of reach if too much traction be used on the tissues. The 
wound is to be closed by sutures. 

Hematoma of Vulva. — This is due to rupture of a vein into the 
loose reticulated tissue of one labium. Enormous distention takes 
place, with discoloration of the adjoining skin as well as of the 
tumefaction. The vulva should be kept clean, and borated talcum 
dusted over the exposed surfaces so as to prevent even the smallest 
breach in the tense skin through which infection may occur. The 
clot is usually slowly absorbed, and should be let alone unless it 
suppurates; then incision and gauze packing are demanded. 

If the patient is seen while the hematoma is forming, the mass 
should be at once opened and the bleeding vessels sought for. The 
cavity made by this procedure if small can be closed by sutures, 
but if large it should be treated by the open method. 

Papillomata or Condylomata. — These warts are due to venereal 
disease or simply to lack of cleanliness. They may form on any 
part of the vulva or adjacent skin. They are firm elevations like 
tufts of the cauliflower blossom; usually occurring in separate 
islets, later coalescing. 

They may be pedunculate or sessile, are of slow growth usu- 
ally, but grow rapidly during pregnancy, and have no tendency 
to become malignant. They are composed of connective tissue 
which springs from the papillae of the skin. Beyond their super- 
ficial external form they have none of the characteristics of papil- 
lomatous carcinoma. 

Symptoms. — These are not distinctive. A ragged outcropping 
from the skin of the vulva, covered by epithelium, firm and at- 
tached to the skin only, sufficiently describes the gross appearances. 



102 GYNECOLOGY 

Treatment. — If the growth be attached by a broad base (sessile) 
it should be scraped away by a very sharp curette and the actual 
cautery applied to the surface. If there be a distinct pedicle, the 
growth may be excised, the incision taking in the skin, and the 
wound closed by sutures. Eesorcin in powder form containing 
one eighth of boric acid and one eighth of subnitrate of bismuth 
may be used as a powder where operation is refused. Eemoval is 
effected under cocaine anaesthesia. 

Hydrocele. — This is a fluid accumulation in a persistent canal 
of Nuck. It is a cystic formation extending from the external 
inguinal ring down into a labium. It can often be reduced un- 
less sacculated. This condition must not be confounded with the 
swellings produced by ascitic fluid being forced into the inguinal 
canals. If sacculated, it is to be treated by aspiration and the in- 
jection into the sac of 50-per-cent carbolic solution in sufficient 
quantity to bathe the entire surface of the sac. But if not saccu- 
lated, open incision and extirpation of the sac is indicated when 
recurrence takes place after aspiration. Among the rarer diseases 
of this region are myxomata, sarcomata, fibromata, cysts of the 
clitoris and of the nymphae, and adeno-carcinomata. These condi- 
tions are so extremely rare that mention only of them is necessary. 

Kraurosis Vulvae. — This is a superficial disease of the vulva 
characterized by a progressive atrophy of certain parts of the vulva. 
There first appear a few painful maculae about the vulval orifice. 
The clitoris shrinks and its glands disappear. The labia and nym- 
phae atrophy so that together they form but a slight ridge upon each 
side. The vulval orifice is rigid and unyielding, and the pudendal 
hair is lost. There is a flattening of the vulva, and the tissues 
of the vestibule become cicatricial. Essentially the disease is a 
proliferation of the connective tissue in the corium, the new cells 
subsequently contracting and producing a condition of sclerosis. 
The cause is unknown. 

Symptoms. — The least touch to the involved area produces pain. 
Coitus is impossible. Pruritus occurs in about one third of the 
cases. After it has lasted some years local loss of sensation super- 
venes and the patient gets relief. 

Treatment. — A pledget of cotton moistened in -J per cent lysol 
kept against the vulva will afford relief. Excision, if extensive, will 
often relieve, but should not be undertaken until limitation of the 
disease is established, lest recurrence take place. 



DISEASES OF THE VULVA 103 

Carcinoma of the Vulva. — As a primary disease carcinoma of 
the vulva is exceedingly rare; it is more frequently seen as sec- 
ondary to cancer of the uterus. It may be found at the meatus 
urinarius, on the clitoris or nymphae. It starts as a nodule cov- 
ered by thickened epithelium, which later breaks down into an 
ulceration. These ulcers spread backward and laterally, but do 
not invade the vagina. It is usually seen after forty years 
of age. 

Symptoms. — In the early stage of infiltration there is pruritus 
vulvae of a persecuting type. Later, when ulceration ensues, there 
is a foetid bloody discharge. The lymphatics are early enlarged, 
not always from extension but from absorption of discharges. The 
cancer nodule on examination is hard and broadly attached to the 
involved organ, but it may have a pedicle. The cancerous ulcer is 
very friable, bleeds readily, and has ragged cedematous borders. 
After ulceration begins extension is rapid. The disease is to be 
differentiated from inflammatory conditions and tuberculosis. 

Treatment. — If extirpation can be practised in such a way as to 
allow the incision to proceed through normal tissue, this should 
be done. Otherwise the surface should be kept clean by curette 
and cautery, followed by mild antiseptic solutions, and the internal 
administration of thyreoid extract. 

The Clitoris. — This may be the seat of any one of the neoplasms 
affecting the vulva. The most common disease peculiar to the 
organ is clitoritis, or inflammation of the glans clitoridis. This 
is usually due to the accumulation and putrefaction of smegma 
beneath the prepuce. It produces oedema of the prepuce and glans, 
redness and itching, and in children may lead to masturbation. 
In adults it is often the cause of a peculiar irritable nervousness. 
The treatment consists in peeling back the prepuce until the coro- 
na glandis is exposed, and wiping off all filth by means of cotton 
and boric-acid solution. The surface is next dried and smeared 
with vaseline. For a few days the prepuce should be peeled back 
each day and the salve again applied. 

Tuberculosis of the Vulva. — This disease is not as rare in the 
experience of those who have large gynaecological services among 
the phthisical as is stated by many. I have seen 4 cases myself. 

The pathology is that of tuberculosis of other muco-cutaneous 
surfaces. The tissues are infiltrated by leucocytes, epithelioid cells, 
giant cells, and tubercle bacilli. 



104 GYNECOLOGY 

The disease can undoubtedly begin as a purely local affection, 
but it may be due to tuberculosis in the genital tract above. 

Symptoms. — At first there is a livid discoloration, then nodula- 
tions of the skin or mucous membrane, rapidly followed by ulcer- 
ation of the caseous infiltrations. The ulcerations are at first sep- 
arated, but soon coalesce to make one large ulcer. The ulcer is 
shallow, its margins irregular and elevated. Bleeding is not easily 
produced, and upon scraping the bottom of the ulcer the pale 
granulations of tubercular tissue are seen. The margins and base 
of the ulcer are not hardened. The ulcers occasionally partially 
heal, but only temporarily. There is little or no pain produced ; the 
discharge is sanious. 

The diagnosis is to be made from cancer and syphilis in the 
early stages and from cancer and chancroid in the later. Multiple 
nodules, then multiple ulcerations, and absence of general glandu- 
lar enlargement, are the chief points upon which syphilis is ex- 
cluded. Chancroid does not cause the diffuse infiltration about the 
ulcer which accompanies tubercular ulceration. With carcinoma 
in its early stages there is seen the single hard elevated nodule, 
perhaps eroded. Later the metastatic nodules are found and the 
adjacent lymphatics are enlarged. Pain is a common symptom of 
carcinoma and is absent in tuberculosis. Microscopic examination 
of a portion excised under cocaine will clear up the diagnosis. 

Treatment. — A wide dissection of the involved tissues is suc- 
cessful in curing the disease. The author has succeeded in remov- 
ing the clitoris, nymphae, labia, and closing the wound by a plastic 
operation at one sitting. The steps of the operation are the same 
as where similar organs are the seat of cancer. The application 
of the cautery and escharotics usually fails and makes a subsequent 
radical removal more difficult. It is probable that the X-ray will 
cure those cases in which the cutaneous surfaces only are in- 
volved. 

DISEASES OF THE VAGINA 

Vaginal Cysts. — These arise from one of two causes : either from 
remains of the duct of Gaertner or from a blocked lymph space, 
possibly from a vein which has become varicosed, obliterated, and 
filled with serum. They are usually single. Earely a vaginal cyst 
will be dermoid. 

There are no distinguishing symptoms. The cyst is fairly 



DISEASES OF THE VULVA 105 

thick-walled with clear contents. Pain is absent. The treatment 
comprises evacuation by incision, exsection of a portion of the cyst 
wall, and the open treatment of the cavity. 

The vagina may also contain chains of calcareous matter, which 
evidently form in the clots of old obliterated veins. Fibroid tu- 
mours, carcinoma, and sarcoma are some of the rarer forms of 
tumour springing from the vagina. When it is possible, complete 
excision is indicated. The embarrassment to this is found in the 
proximity of the two hollow viscera, the rectum and bladder, be- 
tween which and the vagina only thin walls exist. 

Condylomata of the Vagina. — These warty growths have the 
same characteristics as those on the vulva. They are firm and usu- 
ally covered by epithelium, but may be superficially eroded; are 
to be differentiated from papillary carcinoma; and are to be 
removed by the sharp curette, followed by a touch of the actual 
cautery. But if of small size the growth may be excised and the 
wound closed by suture. 

Senile Vaginitis. — It is found in old women and occasionally 
in young women who have been subjected to castration. The tissues 
are injected in spots, and the epithelium is readily rubbed off. Or 
there may be larger or smaller patches which fuse together in 
places, and form constricting adhesions. The condition has been 
likened to buccal psoriasis. The vagina should be kept lubricated 
by lanolin or zinc ointment. 

Tuberculosis of the Vagina. — This may be due to semen from 
a tubercular male or to an extension upward from the vulva, or be 
primary or secondary to uterine tuberculosis. There is at first 
nodular infiltration by cells and bacilli, speedy formation of sep- 
arate ulcerations, then confluent ulcerations. The ulcer is shallow, 
with elevated ragged edges. The floor of the ulcer shows tubercles 
underneath a covering of cheesy material. As the ulceration pro- 
gresses it may open into the rectum or bladder. The discharge is 
watery or purulent and profuse. Pain is absent as also is sensi- 
tiveness. The glands are not often enlarged. 

The diagnosis is not difficult, and is to be made from cases of 
aggravated vaginitis, carcinoma, and syphilis. 

Treatment. — The involved field should always be excised if pos- 
sible. Otherwise the cautery should be used to as great a depth 
as is safe, and injections made into the base of the ulcer of a 
watery solution of metallic iodine (1 to 5,000). The ulcers may also 



106 



GYNECOLOGY 



be painted with tincture of iodine. In case a fistula into the rec- 
tum or bladder has been produced, the tuberculosis should be first 
cured if possible, and then the appropriate plastic operation per- 
formed. 

DISEASES OF THE CERVIX 

Hypertrophy. — This assumes two chief forms: supravaginal 
hypertrophy and infravaginal hypertrophy. 

Supravaginal hypertrophy (Fig. 38) is characterized by an 
elongation of that portion of the uterus which lies between the cer- 

vico-vaginal junction and the 
internal os. The condition is 
found only in the nulliparous 
or primiparous, and is not seen 
in women who have borne chil- 
dren. The great weight of the 
uterus causes it to become pro- 
lapsed, the inversion of the 
vaginal tube beginning above. 

Symptoms. — The mobility 
is less than in true prolapse. 
The condition produces pelvic 
tenesmus, backache, difficult 
defecation, and difficult and 
often painful urination due to 
putrefaction of residual urine. 
Sometimes the case closely 
simulates true prolapse. The 
base of the tumour lies above, 
its apex below; the reverse is 
the case in true prolapse. A 
sound introduced into the blad- 
der and the finger into the rec- 
tum will show that the body of the uterus lies between, a condition 
not present in prolapse. 

Treatment. — The treatment is purely surgical. Inasmuch as 
the uterus cannot be wholly replaced, artificial supports should not 
be used. The cervix should be amputated as high up as possible 
by Schroeder's method, or some modification of that. During heal- 
ing the uterus should be kept as high in the pelvis as possible by 




Fig. 38. — Supra vaginal Hypertrophy of 

the Cervix. 

U, uterine fundus; i?, bladder; F, vagina. 



DISEASES OF THE CERVIX 



10' 



means of vaginal tamponade. The ultimate shrinkage is far greater 
than the decrease immediately produced by the operation; and 
although but a small portion of the hypertrophied organ be re- 
moved, the post-operative con- 
traction is such as to produce a 
marked diminution in the en- 
largement. 

Hypertrophy of the Infra- 
vaginal Portion (Fig. 39). — 
This is characterized by an in- 
crease in the normal structures 
of the portio vaginalis. The 
hypertrophy may be so great as 
to cause the cervix to project 
from the vulva, in which case 
a pressure ulcer on the four- 
chette is not uncommon. The 
enlargement begins in early 
life. The patient is sterile. 
The symptoms are not charac- 
teristic. The diagnosis is read- 
ily made from polypus, inver- 
sion, and prolapse. There is 
found the opening in the cer- 
vix ; the tissue of the mass is 

directly continuous with the uterus above, and rectal examina- 
tion will show the body of the uterus in about its normal position. 
The treatment is surgical only. The cervix should be amputated 
by Schroeder's method or some modification. Not more than two 
thirds of the hypertrophy should be removed lest post-operative 
shrinkage be extreme. 

The condition is not to be confounded with that form of elon- 
gation of the cervix which accompanies one type of anteflexion. 

Cervical Condylomata. — These form upon the vaginal face of 
the cervix. They are usually sessile, being attached by a broad 
base. They may occur as isolated buds, or the entire cervix may 
be covered by them. They resemble papillary cancer upon hasty 
examination, but are firmer, less friable, and do not bleed as easily 
under pressure as cancer. They are covered by epithelium, and only 
exceptionally have superficial ulcerations. They are usually accom- 




Fig. 39. — Hypertrophy of the Infra- 
vaginal Portion of the Cervix. 



108 GYNECOLOGY 

parried by a profuse leucorrhoea, and are often found associated with 
vaginal condylomata. Excision of the affected area is indicated. 

Tuberculosis of the Cervix. — The lesions are identical with 
those of vaginal tuberculosis, only that the density in the cervical 
disease is greater. The symptoms are few and the disease can be 
distinguished from cancer only with difficulty. The microscope 
will clear up the diagnosis either by showing the bacilli or by 
eliminating cancer. 

Tuberculosis of the cervical canal is characterized first by a 
thickening, then ulceration of the glands. The diagnosis is to be 
made by microscopic examination only. Both forms are exceed- 
ingly rare, and are caused by an extension upward from the vagina ; 
but cervical tuberculosis does not cause the disease in the body of 
the uterus, the internal os being apparently the stopping point of 
the ascending process. 

The symptoms are those of endocervicitis. The treatment con- 
sists in a broad amputation of the cervix. 

Vaginismus. — This is a functional disturbance characterized by 
spasm of the levator ani and constrictor vaginae muscles when the 
vulva is touched either during coitus or examination. It is often 
associated with flexures of the uterus which cause dysmenorrhea, 
and may be due to sensitive papillae forming at the point of rup- 
ture of the hymen. The spasm may be so complete as to prevent 
coitus. It is accompanied by pain. If attempts at coitus are per- 
sisted in, laceration of the vagina may occur. The condition does 
not occur unless entrance into the vagina is attempted. 

Treatment. — A strong cocaine ointment may be applied to the 
margin of the hymen, or this may be touched with a 10-per-cent 
cocaine solution. After local anaesthesia is secured, the examination 
can proceed. In aggravated cases not yielding to cocaine, general 
anaesthesia is necessary. During this the remains of the hymen 
should be excised and the vaginal orifice thoroughly dilated. The 
cut edges are then approximated by a running suture of fine tendon. 
At the same time any fault in the uterus should be corrected. The 
condition does not recur after once cured. Sometimes after ex- 
cising the remains of the hymen, the vaginal orifice is kept open by 
the patient wearing during the day Sims's glass plug which was 
designed for this purpose. This is worn for two weeks, being re- 
moved at night. Much domestic unhappiness results from this con- 
dition, which can be corrected by explanation and a simple operation. 



CHAPTER V 



FISTULJE 



Vesico-vaginal, Uretero -vaginal, Recto-vaginal, Uretero-utero-vaginal, Ure- 
thral, Inter visceral, Abdominal, Abdomino -intestinal, Vesicointestinal, 
Vagino-intestinal, Nephro -lumbar, and Other Rarer Varieties 



False passages may be produced by sloughing in the attempt 
of Nature to evacuate harmful products, or by injuries; or be in- 
tentionally made by the physician for therapeutic purposes ; or be 
due to the weakening effect of neoplastic infiltrations upon dividing 
walls. Urinary flstulse are the most 
common, and next in order are the 
abdominal. 

Vesico-vaginal Fistula (Fig. 40). 
— A vesico-vaginal fistula is an open- 
ing in the vesico-vaginal sseptum. It 
is caused by trauma in delivery, acci- 
dentally during operations, purposely 
to drain the bladder, and by cancer- 
ous ulceration. The fistula may be 
but a pinhole opening, or there may 
be loss of nearly the entire saeptum. 
The amount of scar tissue about the 
fistula has an important bearing upon 
the result of operation. The urine 

1 TULA. 

either escapes wholly or partially by 

the vagina. As a result, the bladder is never distended to its full 
capacity; it becomes contracted, inelastic, and atrophied. The 
external genitals are excoriated by urine, and because of her dis- 
ability the patient becomes a recluse. Cystitis is frequent because 
pathogenic germs have ready access to the bladder. 

Treatment. — If the fistula is seen soon after produced and has 
sloughing edges, it is useless to attempt closure, and the sloughs on 

109 




Fig. 40. — The Classical Opera- 
tion for Vesico-vaginal Fis- 



110 GYNECOLOGY 

no account should be trimmed away. The sloughs separate most 
readily when the fistulous opening is well covered on the vaginal 
side by a number of sheets of silver foil. In lieu of this, frequent 
cleansing douches of some mild antiseptic, which will not irritate 
the bladder mucosa, should be used, such as weak formalin solu- 
tions. The fistula should be closed as soon as its edges are clean 
and before the tissues have lost their elasticity. It is well before 
operating to render the urine sterile by the administration for a 
few days of urotropin, and to cure any existing cystitis by means 
of bladder irrigations. 

Operation. — The patient is preferably in Sims's position, the 
operator being seated. The perinseum is held back by a short 
Sims' s speculum and the fistula exposed. If vaginal scars interfere 
with the approximation of the edges of the fistula they should be 
divided, but only down to the vesical mucosa. The edges of the 
fistula are best denuded by means of a very sharp, blunt-pointed, 
straight bistoury, or by means of Sims's scissors. The denuda- 
tion is made in such a way as to form a bevel at the expense of 
the vaginal skin, and the denudation should not include the ves- 
ical mucosa. The haemorrhage is slight. Many variations in the 
technique of Sims have been proposed, but none is worthy of ac- 
ceptance. The use of soft and buried suture material cannot be too 
strongly condemned. The smallest possible needle threaded with 
a carrier and No. 28 or 30 silver wire are to be used. The sutures 
are applied about \ of an inch apart, and are left in place ten days. 

The operation is best done under continuous irrigation with 
normal salt solution. In selecting the direction in which the line 
of approximation shall be made, the surgeon is governed by the 
tension of the tissues. Occasionally the classical bilateral approxi- 
mation must be abandoned for an antero-posterior, or even an 
angular or curved line; but three points should never be 
brought together. The wire is twisted with just that degree of 
tension which secures approximation without strangulation. After 
twisting the sutures and turning the ends so as not to stick into the 
flesh, the line of union is thickly covered by silver foil. The cathe- 
ter should be passed every two hours under the most precise condi- 
tions of cleanliness. After forty-eight hours the catheter is used 
every four hours, and on the fourth day the patient voids. The 
urine should be kept sterile by urotropin, and dilute by the inges- 
tion of large quantities of water. Every second day the wound is 



FISTULA 111 

covered by fresh layers of silver foil. The advantages of the silver 
suture are many. It is not only aseptic but positively antiseptic; 
it does not absorb moisture and therefore does not swell; it can be 
fastened with greater accuracy than any other suture, for the knot 
may be tightened or loosened at pleasure ; the knot never slips, and 
the loop which approximates the tissues never changes its shape. 
It is this latter property of approximation along all parts of the 
loop which gives silver wire an advantage over all other suture 
material. 

Much ingenuity has been displayed by surgeons in dealing with 
fistulae of large size which do not admit of closure by the classical 
method ; notably by Freund, who sutures the uterus into the cleft ; 
by Martin, who turns up lateral vaginal flaps so as to fill in the gap ; 
and by Howard Kelly, who dissects the bladder away from the uterus 
as is done in vaginal hysterectomy, and then sutures the bladder 
walls together in such a manner as to make a transverse scar. 

Uretero-vaginal Fistula. — Ureteral fistulae are seldom the result 
of disease, being usually of traumatic origin. Only occasionally 
will such a disease as cancer cause an erosion and break into the 
ureteral walls. So far as known, inflammations, tuberculosis, 
neoplasms and displacement by neoplasms, do not cause breaks into 
the ureteral lumen. Uretero-vaginal fistulas are of two types : one 
in which the ureter is directly wounded by operative procedure; 
the other when it sloughs because its nutrient vessels are cut off. 
In the first class are included those cases in which the ureter is cut 
or clamped, or sloughs from forcipressure, always in vaginal oper- 
ations. In such accidents the injury is limited to a small area of 
the ureter, and plastic operations more often succeed in closing 
the defect. But in abdominal operations in which the ligation of 
the uterine vessels is effected some distance from the uterus, as a 
rule, the ureter is either kinked by a mass ligature in such a man- 
ner that it sloughs for a considerable distance, or else it is directly 
ligated. Up to an inch, or even a little more, from the bladder, 
the ureter is supplied by a vessel which springs from one of the 
vesical arteries. Outside this point the ureteral artery is a sprig 
from the uterine or even is a branch of the internal iliac. Inas- 
much as abdominal operations in which the ureter is wounded 
usually embrace the removal of the uterus, all the vessels dis- 
tributed to the lower 2 inches of the ureter are more or less inter- 
fered with. This distinction between the manner in which the 



112 GYNECOLOGY 

fistula is produced is of prime importance in determining the 
nature of the operation to be applied for the relief of the fistula. 
The diagnosis is not difficult. In vesico-vaginal fistula a fluid 
colored by methylene blue when injected into the bladder will 
escape into the vagina ; in uretero-vaginal fistula it will not. Direct 
cystoscopy will possibly reveal the old ureteral orifice, but no 
urine will be seen to escape. If the urine drawn from the bladder 
by catheter is measured it will be found that in a given number of 
hours it is about the same as that obtained by a small ureteral 
catheter passed into the uretero-vaginal fistula. Yesieo-vaginai 
fistula? are usually low down, uretero-vaginal are more often near 
the cervix or vaginal scar. By far the preferable operation is the 
following, but is applicable only to those cases in which there is 
little or no loss of the ureteral tube : An opening is made into the 
bladder at the fistulous opening; the bladder is dissected away 
from the uterus high enough up to be sure that the ureter is 
passed: the raw surface thus created on the posterior wall of the 
bladder is then sutured to the artificial fistula, thus folding the 
ureteral fistula into the bladder. Or, the vaginal skin may be 
dissected away from the posterior face of the fistula, the bladder 
entered just anterior to the fistula, the fistula turned upward into 
the bladder, and the wound closed. Some modification of these 
applications of the same principle will usually suffice in small 
fistula?. "When there has been much loss of the ureteral tube, and 
particularly if hysterectomy has accompanied the injury, it is better 
to perform laparotomy, dissect the ureter from its bed and implant 
it into the bladder. Even when the ureter is too short to reach 
the bladder, the bladder may be dropped down so as to reach it. 
After all other means have failed lumbar nephrectomy is to be 
performed. Uretero-utero-vaginal fistula always calls for lapa- 
rotomy and implantation of the ureter into the bladder. If during 
an abdominal operation the ureter is cut, its ends should be accu- 
rately approximated over a flexible ureteral catheter which is passed 
down and out of the urethra, the catheter to be removed in four 
days. Or the ureter may be implanted into the bladder. If both are 
impossible and the patient is strong enough to stand it. the kidney 
should be removed. Or, if the patient is very weak, the ureter may 
be brought out of the incision and the kidney removed later. Im- 
plantation of the shortened ureter into the bowel, as advised by 
some, leads to suppurative disease of the kidney. 



FISTULA 113 

Urethral Fistula. — This is found as the result of injuries in- 
flicted during labour, or from operations. It is closed without 
difficulty, even where large areas of the urethra are lost. If the 
closure produces stricture of the urethra, this is to be dilated by 
sounds after convalescence is complete. Small fistulas are to be 
closed bilaterally in an antero-posterior line, while large openings 
are closed by bringing down the upper edge and uniting it to the 
lower by means of a transverse line of sutures. 

Recto-vaginal Fistula. — The opening may be high up near the 
cervix or low down near the perinaeum. The bowels should be 
thoroughly emptied by a large dose of castor-oil, and the patient 
put on liquid diet. If the fistula is situated near the cervix it is 
to be denuded in the same manner as with vesico-vaginal fistula 
and closed by silver wire ; the sphincter is then paralyzed by stretch- 
ing, and a silver or glass tube 2 inches long and ^ an inch in diam- 
eter is introduced into the rectum; this is worn for six days during 
which the diet is still fluid. If the fistula is near the perinaeum, the 
latter should be cut entirely through so as to make a complete 
laceartion, the fistula trimmed and closed down to the sphincter, 
silver wire being used. The sphincter is closed a month or so later. 

Intervisceral Fistula. — There may be a communication between 
a pyosalpinx and the rectum; or between an ovarian cyst and the 
colon or small intestine ; or between the intestine and the bladder. 
If during an operation for the removal of a pus focus it is found 
that there is a fistula leading into the gut surrounded by slough- 
ing granulation tissue, a grave complication has to be dealt with. 
If the opening is into the small gut and not over J of an inch in 
diameter, the edges of the fistula should be pared and closed by 
Lembert's sutures in two tiers; but when the opening is larger 
such a method of closure would produce too close a stricture, so 
fistulas in the small intestine of \ an inch demand resection of 
the intestines, the anastomosis being preferably by ^Murphy's but- 
ton. If the opening is into the rectum or sigmoid, the edges should 
be pared and sutured if possible parallel with the gut, an abdominal 
or vaginal drain of iodoform gauze inserted, the sphincter ani 
completely paralyzed, and for some days a large tube be kept in 
the rectum to facilitate escape of gases. 

Fistulas between ovarian tumours and the gut are treated in 
the same manner. An appendicular abscess may communicate with 
one of the right adnexa, necessitating removal of the appendix 
8 



114 GYNAECOLOGY 

and inversion of the stump after the adnexal disease has been 
dealt with. 

A fistula between the gut and bladder is rare except when due 
to the encroachments of cancerous infiltration. As a rule, small 
intestino-vesical fistulae close without suture after the intestinal 
lesion has been corrected, merely by keeping the bladder empty; 
but it is safer to carefully suture the bladder opening as well. I 
have seen 2 cases of abdomino-vesical fistula, both of which were 
readily cured by laparotomy and suture. 

Abdominal Sinus. — While this is not a true fistula it is at least 
an opening into the peritoneal cavity and through the abdominal 
wall. The lesion is not uncommon and follows laparotomy in 
which drainage has been used. At the bottom of these tracks are 
either ligatures or a mass of infected granulation tissue. The track 
is tortuous and usually leads down into the pelvis near the pouch 
of Douglas. I have treated and cured 9 such cases by performing 
vaginal hysterectomy, thoroughly cleansing the fistulous track by 
blunt curetting, irrigation of the sinus, and closure of its abdom- 
inal end. In 8 of these cases I recovered silk ligatures. I have also 
tried mere vaginal incision, but have found that with that I could 
not properly cleanse the fistulous track nor sufficiently drain its 
bottom. 

Abdomino-intestinal or Faecal Fistula. — There is a sinus leading 
from an abdominal scar into a pocket in the pelvis, usually in 
Douglas's cul-de-sac. Through this sinus escapes a watery pus 
occasionally containing granular faeces, and intestinal gases con- 
stantly bubble up through the opening. For unknown reasons these 
openings close up spontaneously, remain closed for a time, then re- 
open. While closed they are accompanied by pain and fever; and 
patients having such a lesion soon learn the necessity for providing 
a free escape to the contents of the sinus. The opening into the 
gut is usually in the rectum or sigmoid, rarely into an adjacent 
knuckle of small intestine. In case the lesion is a sequela of appen- 
dectomy the opening will be into the caecum. 

The treatment is embraced in providing a free escape for the 
faeces below and closure of the sinus above. This is usually accom- 
plished by removing the uterus and adnexa by the vagina, in case 
the opening is in the rectum or lower sigmoid, closure of the open- 
ing by suture and rendering the sphincter ani incompetent. If, 
after performing vaginal hysterectomy, it is found that the hole 



FISTULA 115 

in the gut cannot be closed by suture, the vaginal dressings 
should be made to extend above it. After completing the re- 
moval of the uterus free washing of the sinus from above should 
be made before the dressings are inserted. While the operator 
is engaged in the application of the dressings to the vaginal 
operation, an assistant may resect the track of the fistula above 
along its passage through the old abdominal wound, and close 
the opening with silver wire. Even though the fasces discharge 
into the vaginal dressings, they will not become badly soiled 
for some days, and ample time is given for the abdominal por- 
tion of the sinus to close. When this much is secured the 
lower portion of the fistula readily closes under the open treat- 
ment of the vaginal wound. If the sinus leads into a knuckle of 
small gut, it forms one of the gravest abdominal lesions. Such an 
opening is closed only by a wide abdominal section outside the 
involved field, the operator through this freeing all the adherent 
knuckles of gut until the opening is found. This latter is then 
closed either by suture or resection of the bowel and anastomosis 
by the button. In performing such an operation all portions of 
the fistulous tract must be scraped and cleansed as soon as exposed. 
It is utterly impossible to do a technically clean operation in such 
cases, and to employ drainage is to invite the re-formation of the 
sinus. Hence the wound is to be closed, even though the mortality 
is high. 

When a patient presents with a faecal fistula it is important to 
determine, in view of the differing techniques for closing the vari- 
ous forms, the point at which the sinus enters the gut. If it is 
into the small gut, the sinus remains constantly open and dis- 
charges liquid or finely granular faeces ; while if into the large gut, 
it has a tendency occasionally to close, and the faeces are discharged 
in larger lumps. It is my practice in these cases to entirely empty 
the bowels by castor-oil, afterward keeping the patient on liquid 
diet. I attempt to locate the opening in the large intestine in the 
following manner : The patient is placed in the knee-chest posture, 
and normal salt solution is run into the bowel. If the fluid ap- 
pears in the sinus before a pint has entered, the opening is in the 
rectum, the quantity retained before escaping through the sinus 
indicating approximately the height of the opening in the bowel. 

Vagino-intestinal Fistula. — This is occasionally seen after an 
improperly performed, vaginal hysterectomy, and is usually due to 



116 GYNECOLOGY 

pressure of forceps upon the gut. The opening is usually into the 
rectum, rarely into the small gut. The scar should be opened 
through the vagina and the gut pulled down. Its edges are trimmed 
and closed by interrupted sutures of fine kangaroo tendon. The 
wound in the vaginal vault must be partially closed, leaving a small 
opening for a gauze drain, and the sphincter ani rendered incom- 
petent. It is well for the patient to wear a rectal tube for a week. 
If the opening is into the small gut laparotomy is usually de- 
manded; but where the gut lies low down and the vagina is volu- 
minous, the surgeon may attempt resection and either suture or 
the application of the anastomosing button through the vagina. 



DISEASES OF THE URETHRA AND BLADDER 

Urethritis. — Acute. — This is always due either to gonorrhoea or 
caustic irritants when occurring in adults; in children a milder 
type is sometimes due to staphylococci and streptococci. The epi- 
thelium is swollen and in places exfoliated so as to produce small 
ulcerations. The tubular glands of the urethra are clogged with 
epithelium and pus cells. The cocci lie upon the surface, in the 
epithelium, and deep in the glands. They extend up into Skene's 
tubules. The urethra is oeclematous, swollen, and red. Pus escapes 
from the urethra, or the finger inserted into the vagina can be made 
to press pus from the urethra. The condition may be general 
throughout the urethra or limited to the lower portion. The in- 
fection of but a portion of the urethra is more common than sup- 
posed. I found the gonococcus in the urethra of 6 per cent of 
private patients and 26 per cent of clinic cases. It exists in 49 
per cent of prostitutes. In collecting discharge for examination, 
the urethra should be pressed upon through the vagina. 

The symptoms are frequent and painful urination, pruritus, 
and discharge of yellowish or greenish pus. Upon examination the 
pouting, swollen, red urethra is seen to contain a drop of pus. The 
vestibule is inflamed, and punctate spots of red show the mouths 
of the vestibular glands. The orifices of Skene's tubules are 
swollen and reddened. The urethra is sensitive to touch. If the 
urethra is cocainized and inspected through an endoscope the area 
of inflammation as well as the lesions may be well seen. After the 
symptoms have lasted from five to ten days they gradually subside 
and the condition becomes chronic. 



DISEASES OF THE URETHRA AXD BLADDER 11? 

Chronic. — This will assume the type of a chronic superficial 
inflammation or a peri-urethritis. In the first form the mucosa is 
reddened, its vessels unduly prominent, and the urethral folds in- 
tensified and thickened. Digital examination easily detects the 
thickening of the urethral walls, and massage of the urethra from 
the neck of the bladder downward will usually produce a little pus 
at least. If the peri-urethral structures are involved, there will be 
produced an abscess in one or the other of Skene's tubules, or a 
suburethral abscess. This latter condition occurs in but a frac- 
tional percentage of all cases of urethritis. It is an abscess form- 
ing in the vagino-urethral saaptum, is covered by thickened vaginal 
skin, and communicates with the urethra by a small opening. It 
is of slow formation and probably starts in an intensified inflam- 
mation of a particularly long glandular tubule. The purulent con- 
tents escape in gushes at irregular intervals, and can be expressed 
by the finger. The condition is essentially chronic and not accom- 
panied by acute symptoms. The patient will usually complain of 
a " lump " only, perhaps also of the discharge. The abscess may 
reach a diameter of 2 inches. Pressure upon the sac will cause 
pus to flow from the urethra, and then a fine probe can without 
difficulty be introduced into the sac. The opening may readily be 
seen by an endoscope. Gonorrhceal urethritis has a tendency to be- 
come latent and chronic, producing no symptoms. In this state it 
may infect others, extend to the other organs of the afflicted woman, 
or become acute upon the slightest cause. Therefore every case of 
acute urethritis is not an indication of a fresh inoculation. 

Treatment. — Gonorrhceal urethritis in the adult female is a 
disease which may be accompanied by the gravest complications or 
followed by the most destructive lesions. The female urethra, like 
that of the male, is the natural habitat of the gonococcus ; but this 
form of urethritis has in the female far greater significance than 
in the male. Xot only can it seriously damage the urinary organs 
of a woman, but it can also destroy those structures more inti- 
mately identified with reproduction. It therefore becomes the duty 
of the attending physician not only to treat the local condition, 
but also to protect those important organs which lie higher up. 
This latter is accomplished by rendering the urine antiseptic by the 
administration of urotropin, and by keeping in the vagina a light 
pack or iodoform gauze. This is introduced through a speculum 
and should not come into contact with the infected urethra. It is 



118 GYNECOLOGY 

changed once in three days. No local treatment is given while the 
acnte symptoms are present. The urine is increased by taking large 
quantities of water, the patient lies down all the time, and frequent 
bathing of the parts is indulged in, the bath being a very weak 
solution of bichloride of mercury (1 to 20,000). After the disease 
has become subacute — namely, in from five to ten days — the thin- 
bladed bivalve urethral speculum is introduced to the neck of the 
bladder and its blades opened just enough to uncover an appre- 
ciable portion of the urethral mucosa. A cotton-wrapped appli- 
cator is then dipped in solution of nitrate of silver (grains v to 
f 5 j ) and introduced to the end of the speculum. By turning the 
speculum the application may be brought into contact with all 
parts of the inflamed area. This application is to be made every 
day or so, the frequency depending upon the severity of the symp- 
toms. If the gonococcus is still found after using this prepara- 
tion for several weeks, ichthyol in boroglyceride (5 per cent) may 
be applied in the same manner once in three days. No case should 

BE CONSIDERED CURED UNLESS THE GONOCOCCUS IS FOUND TO BE 

absent after repeated examinations. If the infection produces 
suppuration in Skene's tubes these must be slit up and cauterized 
by nitrate-of-silver stick or touched with pure carbolic acid. 

Sub-urethral abscess always calls for an operation. The thick- 
ened walls of the abscess are excised by an elliptical incision, the 
cut edges sloping down to the opening into the urethra. The oper- 
ation should proceed under a stream of sterile salt solution, and 
every particle of the lining of the pus sac must be removed. This 
is facilitated by a large male sound held in the urethra by an 
assistant, thus affording a rigid body against which to cut. The 
resulting raw surfaces are brought together by No. 30 silver wire 
in an antero-posterior direction. 

Urethral Caruncle. — This is in two forms. The more usual is 
that of a pedunculate glistening red body protruding from or oc- 
cupying the urethra. It is a capillary circoid aneurysm covered 
by epithelium, the small vessels forming a network in the growth. 
There may be absolutely no symptoms to denote its presence. But, 
as a rule, ardor urinse, local sensitiveness, and pain darting upward 
are present. In extreme cases the general nervous system will be 
affected. If the growth is bruised, slight bleeding is caused. The 
treatment consists in removal of the growth. This is best done 
by cocainizing the urethra and vestibule, grasping the growth with 



DISEASES OF THE URETHRA AND BLADDER 119 

a tenaculum, and burning it off with the Paquelin cautery so as 
to scar its base. It may be removed by scissors and the wound 
closed by sutures, but is more apt to recur after this. 

In the second form of caruncle the growth is but a protrusion 
at the point of least resistance of a generally varicose urethra. 
The condition is readily seen with the endoscope. It is most often 
found in elderly women, and is one of the most frequent causes of 
recurrence of caruncle after removal. Stricture of the meatus is 
commonly present. Under thorough cocainization the urethra is 
fully dilated by a speculum. Four parallel lines of scarification are 
then made the whole length of the urethra, either with the Paquelin 
cautery, or preferably the fine cautery knife, two lateral, and one 
upon the anterior and posterior walls. This will produce four linear 
cicatrices which effectually correct the condition. 

Urethrocele. — This is frequent in elderly women. It consists 
in a pouching downward of the urethra, and is usually accom- 
panied by narrowing of the external meatus. Hence urine 
accumulates in the pouch, decomposes, and sets up an irritative 
urethritis. The urethral canal should be cocainized. Cocaine is 
next injected into the tissue of the dilatation and a stout sound 
introduced into the urethra. An elliptical piece is cut from the 
urethra, taking in all of its coats except the mucous. The edges 
are then approximated by silver wire in an antero-posterior line, 
and the meatus is thoroughly dilated. The dilatation may have 
to be repeated. 

Urethral Condylomata. — They are due to lack of cleanliness and 
have the same characteristics as similar growths on other parts of 
the vulva. They appear as warty excrescences, are firm, covered 
by epithelium, are pale, and usually pedunculate. They give rise to 
no special symptoms. If attached by a broad base they should be 
excised, and the wound closed by sutures; if by a small pedicle, 
they may be burned off by the Paquelin cautery. Small growths 
require the use of cocaine only, larger ones necessitate general 
anaesthesia. 

Urethral Cysts. — These are cysts of retention formed within 
occluded follicles. They cause no symptoms other than slight 
ardor urinae and dysuria. A urethral cyst may be punctured, 
incised, or extirpated, according to its size. 

Urethral Polypi. — Sarcomata, fibromata, and myomata are 
among the rarer forms of urethral disease, and need no special 



120 GYNECOLOGY 

description. They are mentioned merely to call attention to the 
possibility of their existence. 

Cancer of the Urethra is exceedingly rare. It occnrs as an 
epithelioma of the urethral orifice or as a cancerous infiltration 
of the urethral tube. When found in the first situation it is readily 
removed, and with success both immediate and remote. But when 
found in the walls of the urethra recurrence after removal is ex- 
ceedingly rapid. Tne symptoms are those of urethritis: frequent 
painful urination, discharge of blood and pus, later incontinence 
of urine, etc. In the epithelial type of the disease bleeding and 
discharge early accompany the ulceration; while in carcinoma of 
the urethral tube dysuria from obstruction is a marked symptom. 

The diagnosis is readily made. The presence of a growth which 
is exceedingly friable, bleeding to the least touch, having a hard 
infiltrated base and rapidly extending, are the differentiating 
features of cancer. Most of the patients are over fifty years 
of age. 

As long as the involved tissues are not attached to the pubic 
bone but remain movable, extirpation should be practised. 

Operation. — This is applicable to malignant neoplasms, and 
should include all walls of the urethra. At a point above the 
growth sufficiently high to guard against recurrence the surgeon 
cuts transversely through the vagino-urethral sseptum. A sound 
in the urethra will act as a guide and fix the tissues. After 
the urethra has been entirely cut across an elliptical incision is 
carried downward from each end of the transverse cut to the side 
of the meatus. Eemoval of the tissues thus circled is more readily 
made from above downward, and traction upon the urethra by 
tenacula will facilitate dissection of the urethra from the pubis. 
The bleeding is very active but from small arterial trunks, branches 
of the external iliac artery. Each should be seized and ligated by 
very fine catgut. The severed urethra will now be found to be 
at the bottom of a deep wound and opening into the vagina. An 
attempt must now be made to draw out the urethra and fold in the 
vulvar edges of the incision so that the two will meet. This is first 
done with the anterior portion of the vulvar incision, this area 
being the most movable. The approximation of the lateral edges 
to the urethra is more difficult, and may be facilitated by removing 
the loose fat lying beneath the cutaneous edges of the incision. 
Silver wire is the preferable suture material, as it does not become 



DISEASES OF THE URETHRA AXD BLADDER 121 

infected by the discharges. The patient should not be allowed to 
void urine, but a small catheter must be used once in three hours 
to empty the bladder for the first two days at least. Dry boric-acid 
powder dusted over the field of operation will prevent excoriation. 
After this operation the urethra will open beneath the pubic base, 
and the patient should always be careful to separate the labia when- 
ever urinating, and to exercise scrupulous local cleanliness. 

Dilatation of the Urethra is not infrequent. It is produced by 
rough intra-urethral instrumentation, by coitus through the ure- 
thra, and by labour. The circular fibres of the urethra are either 
ruptured or so stretched that they no longer contract. The digital 
exploration of the bladder and removal of vesical stones cause some 
of the lesions, but by far the greater number result from labour. 
In his eagerness to save the perinseum the accoucheur crowds the 
occiput up against the symphysis, and as the head is forced down 
it pushes before it the urethra. As a result not only are the cir- 
cular fibres torn, but the urethra may even be detached from the 
pubic base. 

The one cardinal symptom is incontinence of urine, either occa- 
sional, upon effort, or constant. The orifice of the urethra is not 
rounded or oval, but is usually a bilateral slit. 

Treatment. — A soft, air-filled rubber ball of size sufficient to 
press the urethra against the pubis may be inserted into the vagina 
each morning. This failing to afford satisfactory relief, a con- 
siderable area of the urethro-vaginal saeptum must be resected, and 
the raw surface so sutured as to throw up into the lumen of the 
urethra a marked longitudinal fold when the stitches are tied. 
It is not necessary to enter the lumen of the urethra, although I 
have resected even that without detriment, and effected a cure. 
Silver wire is the proper suture material. 

Urethral Stricture is found at any point of the urethra, but 
most often at the meatus. Carcinoma, scars from venereal ulcers, 
repeated attacks of gonorrhoea, may all cause stricture ; but by far 
the greater number of strictures at the meatus are of unknown 
origin. When due to cicatricial tissue, the treatment is by dilata- 
tion, or incision followed by dilatation. This treatment can be 
conducted under cocaine. Stricture due to cancerous infiltration 
should be let alone. When retention of urine due to a close stric- 
ture renders the continuous use of the catheter necessary, an arti- 
ficial vesico-vaginal fistula must be made and kept open. 



122 GYNECOLOGY 

Cystitis. — This is caused in about 60 per cent of cases by a 
bacillus of the colon group (Bacillus pyogenes, or Bacillus coli 
communis, or Bacillus aerogenes, as called by different authors) ; 
next in frequency as a cause is the gonococcus; then the tubercle 
bacillus, and others less frequently. The infections are rarely 
pure, being usually mixed, and any or all of the pyogenic cocci 
may be associated with the three chief causes I have given. The 
predisposing causes are constipation, retention of urine, inability 
to empty the bladder completely, trauma, as labour or instrumenta- 
tion, long exposure to cold, and any condition which will mechan- 
ically injure the bladder or reduce its vitality. The causative 
germs may enter through the urethra by the blood or from adja- 
cent organs. The disease may be limited to the trigonum, its 
most frequent site, or occupy the peritoneal segment of the blad- 
der, or the pubic segment, or it may involve the entire organ. 
Tuberculosis of the bladder will be separately described. The 
exanthematous fevers may also cause cystitis, which in later years 
will produce " contracted bladder." 

In acute cystitis the inflamed area is deeply injected, swollen, 
and petechial haemorrhages may occur. The epithelium is covered 
by pus cells. The process may cease naturally or become chronic. 
In chronic cystitis the rugae are adherent in many places, the 
mucosa is pale and thickened, or injected and presenting super- 
ficial ulcers with escape of blood. The process may be limited to 
the mucosa or extend to the submucosa, with the production of 
abscesses {'parenchymatous cystitis), and greater or less portions of 
the mucosa may be exfoliated. The urine is turbid, contains pus, 
epithelium, blood-cells, possibly clots and gas bubbles. 

Symptoms. — In the acute stage there are frequent and painful 
urinations ; vesical tenesmus both before and after urinating ; pain 
over the pubis and sensitiveness to pressure may be present, and the 
passage of the catheter gives great pain. The patient has to rise 
many times during the night, and broken rest adds to the depre- 
ciation in health. Most cases recover from the acute stage and 
pass into the chronic. Frequent urination is then the most marked 
symptom. The patient rises a certain fixed number of times each 
night because the bladder will retain but a limited quantity of 
urine. In the acute stage the irritability of the mucosa compels 
frequent evacuations, and the exfoliation of epithelium allows the 
approximated rugae to adhere. As a result the bladder is held in a 



DISEASES OF THE URETHRA AXD BLADDER 123 

condition of permanent contraction, it cannot distend beyond a 
certain point, and the muscular walls present a thickened appear- 
ance. The full recognition of this result of the inflamma- 
tion IS OF the utmost importance when we consider the 
treatment. The inflammatory process may extend up into the 
ureters, one or both, and then into the pelvis of one or both kid- 
neys. This upward extension is most likely in gonorrhoeic and 
streptococcic infection, and least often seen in colon bacillus cys- 
titis. 

Diagnosis. — It is not only necessary to determine the degree 
of the involvement, but also its exact nature and, if possible, detect 
the causative micro-organism. This precision may be postponed 
until after the symptoms have subsided, but may be necessary 
during the acute stage. A careful examination of the genitals 
should be made to detect gonorrhoea of other structures. A chem- 
ical, microscopic, and bacterial examination of the urine is neces- 
sary, and the urine measured for a day. By means of cystoscopy 
the exact condition of the vesical mucosa can be determined. 

Treatment. — Acute cystitis is not to be "let alone/' but should 
be actively though intelligently treated. The pain is to be relieved 
by tr. hyoscyami, tt[ xxx q. 6 h., with possibly a little laudanum. 
The urine is rendered sterile by the internal administration of 
urotropin, cystogen or large doses of benzoate of soda, in order to 
limit the likelihood of extension of the disease into the ureters. 
Concentrated urine is irritating, therefore large quantities of water 
should be taken. The local treatment is most important. The 
urethra should be cocainized by injecting into it a 4-per-cent solu- 
tion of cocaine by means of a slender curved syringe. The syringe 
is introduced to the bladder neck, and the injection is made along 
the urethral track as the syringe is withdrawn. In five minutes 
a soft catheter can be painlessly introduced into the bladder, and 
the bladder washed with a l-to-32 solution of borolyptol or 1-to- 
20,000 formaldehyde solution. The bladder should be filled to the 
point of tolerance, but not distended beyond this, so as to unfold 
all the rugae which, when adherent, retain the pus; this solution is 
allowed to run out, more is injected, and this allowed to escape. 
The washing is preferably conducted with a funnel and rubber 
tubing, which apparatus enables the operator to note the speed with 
which the fluid enters, and the bladder should be very gradually 
distended to guard against spasm. The procedure is to be carried 



124 GYNAECOLOGY 

out twice a day Irrigation through a double catheter is 

WORSE THAN USELESS OWING TO THE RUGOUS FORM OF THE BLADDER 
WHEN CONTRACTED. 

Chronic Cystitis. — This is rarely general over the entire bladder 
mucosa, but is generally limited to the trigonum and uterine seg- 
ment. The involved area may be injected, the vessels standing out 
prominently, and occasional spots of pus may be seen. If ulcers 
are present they are usually very small. Or the mucosa may be 
unusually pale, irregularly ridged by bands of connective tissue in 
the submucosa, and the rugae may be seen adherent in places. This 
form is more a sequela than a type of inflammation. The chief 
symptom of the true chronic cystitis is the necessity for frequent 
urination and urgency in the desire. The urine will contain pus 
and occasionally blood. Microscopically we find bladder epithe- 
lium, bacteria, pus, and blood-cells. There is no acute pain, and 
unless the bladder be contracted the patient may not have to rise 
at night to urinate. Even pressure upon the bladder may fail to 
develop sensitiveness, but intravesical instrumentation is painful. 
If the bladder be contracted the patient must empty it frequently. 
This contraction may be so great that the organ will receive not 
over an ounce of fluid. In such an extreme case the patient will 
be found to have enuresis while asleep. One case I had was a 
young lady who had contracted a cystitis from scarlatina, which 
resulted in this form of shrunken bladder. She carried with her 
wherever she went her own rubber, sheets, and linen, and slept 
throughout the night to awaken each morning in a pool of urine. 
She was entirely cured by treatment. No greater distress can be 
imagined than that accompanying an extreme degree of contraction 
in the bladder. Every case of chronic cystitis should be subjected 
to a thorough cystoscopy for the purpose of accurately estimating 
the extent and character of the lesions. If ulcerations are seen 
they should be touched with nitrate of silver. In all cases the 
bladder should be washed out once or twice a day with an appro- 
priate solution, preferably formaldehyde (1 to 20,000), the sensa- 
tions of the patient governing the amount. If the bladder be con- 
tracted, progressive dilatation must be practised. To secure this, 
each day a greater amount of fluid must be inserted. The daily 
gain may not be much over J an ounce, but the treatment must be 
persisted in until the bladder will retain at least 12 ounces. When 
no active inflammation exists it is not necessary in securing dila- 



DISEASES OF THE URETHKA AND BLADDER 125 

tation to use any strong antiseptic. In such a case saturated 
boric-acid solution or saline solution is best. By far the preferable 
apparatus is the graduated glass funnel, rubber tubing, and soft 
catheter. The bladder should never be distended by a bulb-syringe, 
because the pressure cannot be accurately governed nor the amount 
injected measured. Besides, it is difficult to sterilize a bulb-syringe. 
As the adherent rugse separate a little blood may be produced. Old 
women who have contracted bladders cannot be trusted to deter- 
mine the degree of distention by their sensations, for they are par- 
ticularly indifferent to pain. Distention up to 8 ounces at the 
first sitting is sufficient. This treatment is not applicable when 
the bladder walls are disintegrated by either carcinoma or the 
caseous type of tuberculosis, and the possibility of such conditions 
must be eliminated before the treatment is begun. This method 
of treating chronic cystitis renders it unnecessary to form an arti- 
ficial vesico-vaginal fistula. 

Exfoliative Cystitis. — Any condition which shuts off the circu- 
lation of the bladder may cause sloughing of the mucosa. If the 
bladder be enormously distended such a result may follow; or if 
the uterus becomes suddenly retroflexed, or pressed upon by a tu- 
mour, sloughing may result. The symptoms are great pain, fever, 
bloody urine, shreds of tissue in the urine and pus. The pain must 
be relieved by opiates. Careful watch is to be kept lest the shreds 
of tissue block the urethra and cause overdistention of the bladder. 
The loose tissue is to be picked and cut away, and the bladder kept 
clean by repeated irrigations with boric acid, not accompanied by 
distention. The cause of the condition must be removed. 

This is the form of cystitis which is sometimes seen to accom- 
pany the profound systemic infections, such as septicaemia, typhoid, 
scarlatina, and measles. 

Tumours of the Bladder. — The most common form of primary 
growth is the papillomatous fibroma. It is a papillary growth, 
usually pedunculate, covered by thick epithelium, and commonly 
springs from the uterine segment. The growth arises from the 
mucosa, does not invade the submucous structures, and is com- 
monly single. It is very vascular and bleeds easily. It may be 
found at any age. The mobility of the growth can well be appre- 
ciated in an examination through the cystoscope. When the diag- 
nosis is clear, the growth should be removed by a curette forceps 
which will pinch out a bit of the mucosa from which the growth 



126 GYNECOLOGY 

springs. It must not be forgotten that bladder cancer occasionally 
assumes the form described. 

Among, the rarer bladder tumours may be mentioned dermoid 
cysts, myomata, fibromata, sarcomata, and carcinomata. 

Carcinoma of the bladder, when primary, assumes, as a rule, 
the papillomatous type, rarely presenting necrotic ulcers due to 
breaking down of infiltrated spots. The readiness with which 
such growths bleed and their exceeding friability easily distin- 
guish them. Furthermore, they are nearly always multiple. 
Cancerous extension to the bladder from the uterus usually first 
manifests itself as a submucous nodular infiltration about the 
trigone. 

Symptoms due to vesical tumours : Pain is not often present 
unless a severe degree of cystitis coexists or blood-clots form in 
the bladder. Urgency and frequency in urinating are common 
symptoms. Haemorrhages into the bladder are common in cancer, 
and occasional in papilloma and fibroma. There may be small 
clots which become decolorized, or a large clot may form and be 
sufficient to block the urethra. 

If the growth is large enough, or situated near the urethra, it 
may produce suppression. The diagnosis is made by direct cystos- 
copy, urinalysis, and examination of specimens of the tumour, 
which should be removed through the urethroscope. 

The treatment is dependent upon the nature of the growth. 
Any non-malignant growth capable of passing through a 32 F. cys- 
toscope should be removed that way. Larger tumours can be taken 
out through a vaginal incision or a suprapubic operation, the size 
determining. Malignant tumours of the bladder, in which the dis- 
disease is localized in that organ, demand its total extirpation 
with implantation of the ureters into the vagina. 

Ureteritis. — Acute. — Any of the pus-producing organisms may 
cause it as well as the tubercle bacillus. It is due most often to 
an extension from the bladder, but may be an inflammation descend- 
ing from the kidney or originating in the ureter at some point 
damaged by trauma, as by a calculus. The mucosa of the ureter 
becomes swollen, reddened, and the epithelium is exfoliated. Pus 
is produced in abundance. After a time the submucous walls of 
the ureter become thickened and may remain so. The urine es- 
caping through the affected ureter may contain pus, bacteria, epi- 
thelium, and blood. 



DISEASES OF THE URETHRA AND BLADDER 127 

Symptoms. — The extension of an infection upward from the 
bladder is often ushered in by a chill. The temperature rises 
rapidly and the course of the ureter in the pelvis is markedly sen- 
sitive. This symptom can be elicited by vaginal or rectal palpa- 
tion. If the inflammation be due to a calculus the symptoms will 
be those of stone in the ureter rather than of inflammation, be- 
cause this latter is of gradual onset. If the ureteritis be due to a 
downward extension of a pyelitis the symptoms of the two con- 
ditions are indistinguishable. Upon making a cystoscopic exam- 
ination the orifice of the affected ureter will be seen to be cedema- 
tous, inflamed, and the urine discharged will be purulent or bloody. 

In chronic ureteritis the fever is irregular or entirely wanting. 
Pain in the affected side is constant, and there is more or less ardor 
urinse. The urine contains ureteral epithelium, pus, and often 
blood. In all cases of ureteritis a careful bacteriological examina- 
tion should be made of the urine so as to determine the direct 
cause of the disease. In all cases of general acute ureteritis, and in 
some of the chronic forms, a mild leucocytosis is present. 

Diagnosis. — In the acute form this is often difficult. If occur- 
ring on the right side the case may be interpreted as one of appen- 
dicitis, an error which is particularly easy, as leucocytosis exists 
in both conditions. But a careful analysis of symptoms, the ex- 
haustive examination of the urine, the presence of vesical symp- 
toms, the absence of abdominal rigidity and sensitiveness, and 
the presence of ureteral sensitiveness, will enable the observer to 
exclude most of the diseases for which ureteritis may be mistaken. 

Treatment. — Acutely inflamed ureters are not to be touched. 
The patient is to be given sufficient opium to allay pain. The urine 
should be rendered sterile as far as possible by the administration 
of urotropin for some days. If acute cystitis exists, as is usually 
the case, this must be energetically treated. The ureter has a par- 
ticular resistant power against germs, and will usually recover if 
the causative cystitis is cured. The bowels are kept empty so as 
to avoid pressure by scybalous masses. 

After ureteritis has become chronic an effort must be made 
to effect a radical cure. As a first step it is essential to determine 
which ureter is involved, or whether both are. Under cocaine the 
ureters are to be catheterized with the utmost care by means of 
direct cystoscopy. The catheters are introduced only into the pel- 
vic portions of the ureters. The relative speed with which the two 



128 GYNAECOLOGY 

kidneys functionate, as well as the gross appearances of the speci- 
mens, can be noted in half an hour. The catheters are then with- 
drawn and the bladder irrigated with formaldehyde, 1 to 20,000. 
A dose of 10 grains of quinine with a grain of opium will tend to 
prevent a chill and quiet the patient. A careful chemical and 
bacteriological examination of the specimens is now made. If the 
ureteritis be due to streptococcus it will usually be found asso- 
ciated with pyelitis. If due to the colon bacillus it is often pri- 
mary but also accompanies renal calculus. If due to the gonococcus 
it rarely extends to the kidney. In all forms of chronic ureteritis 
a cure cannot be effected unless the coexisting complications in 
bladder or kidney be overcome. If the ureter remains inflamed 
after the kidney and bladder are rendered normal, it should be 
washed out once in three days with boric acid, which is substituted, 
as soon as the catheterization of the ureter is found to be free from 
risk, by borolyptol, 1 to 40. Irrigation of the ureter is a most diffi- 
cult and technical procedure, and is not to be attempted by every 
one. As a rule the attendant will content himself with curing a 
possibly infected kidney or bladder, and indirectly treating the 
ureter by agents which sterilize the urine. In considering ure- 
teritis, IT MUST NOT BE FORGOTTEN THAT IT IS RARELY PRIMARY. 

If the kidney be riddled by pus so as to demand removal, the 
ureter also is to be taken away or a sinus may form. 

Stricture of the Ureter. — This is nearly always limited to that 
portion which passes through the true pelvis. Furthermore, it is 
most often in the vesical wall that we find such strictures. It may 
be due to tuberculosis (described later) or neoplasm of the ureter, 
but true stricture is generally the result of ureteritis or peri- 
ureteritis. As a result of such stricture a hydro-ureter or pyo- 
ureter may develop. The affected ureter is to be gradually dilated 
through a cystoscope by the introduction of graduated whalebone 
bougies. Peritonitis and parametritis may produce bends or 
obstruction in the ureter. Given a history of peritonitis or puer- 
peral sepsis and obstruction of the ureter through which the small- 
est ureteral catheter cannot pass, peri-ureteritis with stricture may 
be diagnosed, and is to be relieved by laparotomy. 

Cystoscopy (Fig. 41). — The bladder may be examined by indi- 
rect illumination or by direct, the latter being preferable. This 
may be clone either by means of the male cystoscope, in which case 
the bladder is distended with water, or by the female cystoscope. Of 



DISEASES OF THE UEETHRA AND BLADDER 129 

all methods the one giving the greatest satisfaction is that which 
makes use of distention by air. This may be accomplished by 
forcing the air into the bladder; but emphysema has been known 
to follow this procedure, and treatment of the bladder is impossible, 
as this method is possible only with a closed cystoscope. Posture 




Fig. 41. — The Author's Method of Direct Cystoscopy, "without the Use of 
Mirrors or Head Lamps. 

should be employed to distend the bladder, so that the air is drawn 
into the dilating organ. The bladder is emptied by a catheter. 
The patient is placed in the knee-chest posture, and the cystoscope 
of Kelly introduced. Immediately the bladder distends, the rectum 
seeks the curve of the sacrum, and the anterior wall of the vagina 
does the same. This latter fact militates against the ready inspec- 
tion of the ureteral orifices and catheterization of the ureters. 
AVI ion this is found to be the case a light vaginal tampon of cotton 
should be employed to hold up the anterior vaginal wall. The 
bladder is illuminated by a head mirror or forehead lamp. The 
9 



130 GYNECOLOGY 

author's method is the following : The bladder is emptied by cath- 
eter. The patient is then placed on the back with the thighs flexed 
on the abdomen. The author's cystoscope is then introduced and 
the table lowered into Trendelenburg's position. If the clothing 
be loose, the bladder immediately distends with air. Upon turning 
on the electric current the bladder at once becomes illuminated as 
illustrated. The entire organ may be inspected by turning the 
instrument; intravesical operations and applications may be made, 
foreign bodies removed, and the ureters readily catheterized. The 
larger cystoscope corresponds to the 30 F. scale. Its use necessi- 
tates cocaine and dilatation only where stricture exists. After 
the manoeuvre the bladder is washed out with borolyptol (1 to 32) 
solution. 

Catheterization of the Ureters. — This is done for the purpose 
of securing separate specimens of urine for examination, and is a 
most valuable aid in diagnosing ureteral and renal disease. It 
should never be employed when the bladder or ureters are acutely 
inflamed. The fine flexible catheters of Kelly are sterilized by 
boiling three minutes in plain water, or preferably by formalin 
gas. The small cystoscope is introduced and the bladder distended 
as just described. One ureter is found and the catheter passed 
for about 4 inches. The cystoscope is then withdrawn and rein- 
troduced alongside the catheter, the other ureter found and a 
catheter passed into that. The cystoscope is finally removed, and 
the patient carefully placed in bed so as not to disturb the cath- 
eters. The catheters are now inserted into test-tubes the orifices 
of which are loosely plugged by absorbent cotton, and the tubes 
held tilted up by a roll of cotton. After sufficient urine is secured, 
the catheters are removed and the bladder is washed out. It is well 
to use catheters of different colours so as to know into which ureter 
each is inserted, and the test-tubes are to be marked " right " and 
" left," to designate the ureters from which the specimens were 
drawn. 

Tuberculosis of the Bladder. — This may be primary, due to an 
introduction of the bacilli through the urethra, in which instance 
the trigone is first invaded ; or be secondary to a renal tuberculosis 
which has extended downward, and then the first evidence of in- 
volvement of the bladder will be about a ureteral orifice. The dis- 
ease may begin as a miliary type, the affected area being studded 
with minute round elevations of light colour and covered by epi- 



DISEASES OF THE URETHRA AND BLADDER 131 

thelium; or start as a cellular infiltration of the deeper layers of 
the mucosa, forming caseous spots. These latter break down and 
produce ragged ulcers. The process may invade all the walls of 
the bladder or be confined to one spot. As the disease spreads the 
bladder-walls contract, so that the capacity of the cavity may be 
less than an ounce. In the early stage the urine will contain epi- 
thelium and pus, but when ulceration begins blood in quantity is 
produced. The disease may occur at almost any age, is sometimes 
acute, but usually assumes a chronic type. The bacilli of tubercu- 
losis may usually be found in the urine, or can be secured by 
curetting a small area of an ulcer through the cystoscope; but 
occasionally the urine will show its character only when injected 
into the peritoneal cavity of the guinea-pig. About 10 per cent 
of all cases of cystitis are due to tubercle bacilli. 

Symptoms. — Pain on urinating is the first symptom and is of 
a stabbing character. The patient urinates more frequently than 
usual, and may notice a sediment of pus and mucus in the urinal. 
Hematuria is a common symptom, the blood being in large quan- 
tities or appearing as small pale clots. There is loss of weight and 
general weakness. The temperature may be continuously high or 
rise only in the evening. The pulse conforms to the temperature 
and general strength. Upon cystoscopic examination the miliary 
tubercles or ulcerations may be seen. It is always advisable to 
catheterize both ureters through the cystoscope, thus securing sep- 
arate specimens from the two kidneys for careful bacteriological 
examination. It is important to determine whether the kidneys 
are involved. 

Treatment. — This cannot be intelligently carried out unless 
not only a diagnosis of the cause of the cystitis be found, but also 
the limitation of the invasion be determined. In miliary tuber- 
culosis of the bladder, the best treatment is found in washing the 
bladder out once each clay with an aqueous solution of metallic 
iodine in strength of 1 to 5,000, or even 1 to 30,000. In doing this 
the bladder cavity is to be distended with fluid and the solution is 
to be retained some minutes if possible. Or an emulsion of iodo- 
form in any bland oil may be injected into the bladder in 10- to 
50-per-cent strength. If small ulcers are seen, they should be 
curetted and touched with pure tincture of iodine or with 20-per- 
cent nitrate-of-silver solution. Frequent irrigations with boric 
acid or formalin (1 to 10,000) are to be employed between the 



132 GYNAECOLOGY 

applications. If the ulcers are large or numerous, so as to pre- 
clude the general curettage of the bladder, the irrigations with 
iodine solutions are to be used. 

When the entire bladder is involved and the kidneys normal, 
removal of the bladder and implantation of the ureters into the 
vagina is to be considered. 

Tuberculosis of the Ureter. — This is nearly always secondary 
to a renal tuberculosis. The disease manifests itself in the forma- 
tion of caseous granulomatous masses. The entire ureter is thick- 
ened and adherent to the adjacent structures. The symptoms are 
those of chronic ureteritis. There is a profuse production of pus 
admixed with which we often find much blood. As primary tuber- 
culosis of the ureter is unknown, the symptoms are masked by 
those of the causative disease. The only treatment which gives any 
hope of cure is removal of the entire ureter, of course with the 
kidney. The ureter may be removed either through the long loin 
incision of Howard Kelly, and the stump of the ureter turned into 
the vagina through an incision at the vaginal vault, or through 
a transperitoneal incision. The latter operation I prefer. An 
incision is made in the linea semilunaris (Langenbeck's incision) 
and the peritonaeum severed. The incision 
extends from the level of the eighth costo- 
vertebral joint to the pelvic brim. After the 
kidney is removed and the ureter tied close 
to the kidney, the ureter is freed by blunt 
dissection and with great care so as not to 
wound the colica vessels. It is safe to in- 
cise the peritonaeum where the ureter crosses 

Fig, 42. -Appearance the P eMc brim > S0 aS to aSsist in freein g 

of the Vesical End the ureter from its attachments above the 
of the Ureter Six pelvis. In the pelvis it is necessary to dis- 

MoNTHS AFTER LviPLAN- , i ii ■ -, .... ,. 

tation of the Ureter Sect 0nt the Ureter doWn to lts insertion 

into the Bladder, in into the bladder until it can be drawn 
a Case of Extirpa- U p i n f ron t of the uterine artery. It is 

tion by Laparotomy ,-, , ™ . , . n . -, 

of the Cancerous then Cnt ° ff ' A P r ° be Wlth an e J e 1S P aSSed 

Pelvic Organs. through the stump into the bladder and 

out of the urethra. A suture is passed 

through each side of the ureter and into the eye of the probe, 

then tied. An assistant draws clown upon the probe and thus 

inverts the ureteral stump into the bladder. A few sutures 




DISEASES OF THE URETHRA AXD BLADDER 133 




then suffice to close over the depression in the bladder-wall, the 

peritoneal edges are sutured, and the abdomen closed. The pres- 
ence of the probe in the bladder in no 

way interferes with the passage of the 

catheter; and in a few days the sutures 

which were used to invert the ureter cut 

their way through and the probe can be 

removed. The bladder after this opera- 
tion is daily washed with formaldehyde 

(1 to 10,000), or aqueous solution of 

iodine (1 to 10,000), until a cystoscopic 

examination shows that the stump of the 

tubercular ureter has sloughed away. 

Vesical Calculus. — Stone in the fe- 
male bladder sometimes results from an 

enlargement of a small calculus which 

has dropped into the bladder from the 

ureter; but most of them have as nuclei 

a bit of cotton, a catheter end, a hair-pin, 

or a piece of chewing-gum (Fig. 43). 

intraperitoneal operations, or in the vagina, may wander into the 

bladder and be nuclei for cal- 
culi. The symptoms are those of 
cystitis. If the stone be sharp or 
the foreign body have a cutting 
edge, blood will be produced. Fre- 
quent and painful urination, the 
presence of pus and blood in the 
urine, will suggest an examination. 
Unlike other forms of cystitis, 
patients with calculi are more 
comfortable with a moderately dis- 
tended bladder. The bladder is 
most painful when empty. The 
foreign body may be felt if large 
by vaginal examination, or give 
out a distinct " click " when a 
sound is introduced. Cystoscopy 

will easily show the calculus and determine its size and form. 

The treatment embraces the removal of the calculus and cure 



Fig. 43. — A Calculus formed 
around a Hair-pin which 
had escaped into the blad- 
DER. 

Eeraoved by vagino-vesical sec- 
tion. 

Ligatures employed in 




Fig. 44. — The Head of a Self-re- 
taining Catheter, broken off in 
its Eeaioval and encrusted by 
Crystal of Urates. 

The presence of this foreign body was 
not confessed until three weeks after 
the accident. (Enlarged twice.) 



134 GYNAECOLOGY 

of the cystitis (Fig. 44). Through the large cystoscope most 
calculi can be broken up and removed. Those too hard or too 
large for this can be removed by vaginal cystotomy or suprapubic 
cystotomy. 

Ureteral Calculus. — These are but stones which have passed 
from the kidney. Most of them are formed of urates. Occasion- 
ally a foreign body like a ligature will enter the ureter and form 
the nucleus of a stone. As soon as the stone enters the ureter an 
attack of renal colic sets in. The agonizing pain shoots downward 
into the bladder along the thigh and groin. The pain is constant, 
with most distressing paroxysms. A rigor often starts an attack, 
and during it vomiting, profuse sweating, and incontinence of 
urine occur. The urine is generally bloody. An attack may last 
for hours and be many times repeated, or may suddenly disappear. 
Cessation of the pain does not necessarily denote escape of the 
stone into the bladder; it may merely have passed into a little 
more dilated portion of the ureter. If the stone is in the pelvic 
portion of the ureter it may be felt by vaginal or rectal touch. 
If situated higher up, it may be felt with a whalebone ureteral 
bougie passed into the ureter through a cystoscope or by Kelly's 
wax-tipped bougie. The stone may be passed or become impacted. 
After an attack of renal colic has ceased, a careful search for 
the stone either in the urine or bladder should be made. If an- 
other attack occurs and the stone has not been found, it is prob- 
ably impacted. It is then necessary to try to locate the point of 
impaction. As a rule the impaction is below the pelvic brim. Im- 
paction conduces to hydronephrosis, pyonephrosis, and death. Or 
local ulceration may occur, the ureter be perforated, and death 
ensue from septic peritonitis. An impacted stone may remain for 
a long time without producing serious symptoms, or may cause 
menacing symptoms soon after becoming fixed. 

Treatment. — During the attack of colic the pain is to be relieved 
by large doses of morphine. If the stone becomes impacted in the 
abdominal portion of the ureter, it is to be removed by a loin 
incision. If it is impacted in the pelvic ureter, transperitoneal 
uretero-lithotomy is indicated. After exposing the ureter the stone 
should, if possible, be shoved a little away from its point of lodg- 
ment, where in all probability an ulcer has formed, before the 
ureter is incised. The ureter should be incised parallel with its 
course, and after the stone is removed the incision closed by fine 



DISEASES OF THE URETHRA AND BLADDER 135 

interrupted sutures. Occasionally a stone will lodge in that portion 
of the ureter which crosses the vagina, and it can then be removed 
by vaginal incision. In all cases of ureterectomy for stone, a long 
flexible ureteral catheter should be passed down the ureter and out 
of the urethra, to insure free escape of the urine while the incision 
in the ureter is healing. It can be removed in three days. 



CHAPTER VI 
TUMOURS OF THE PAROVARIUM AND OVARY 

Parovarian Cyst (Fig. 45). — This arises from the remains of 
the parovarinm. The canse is unknown, and it may be found at 
any time of life. It is essentially intraligamentary ; but when it 
begins in the outer part of the parovarium and evolves towards the 
abdominal cavity it may become pedunculated. As it spreads 
apart the folds of the broad ligament it infringes upon the side 
of the uterus and becomes sessile upon it. It may grow to such 
size as to lift the peritonaeum up from the pelvic floor and lateral 
pelvic walls, in which case it may have the ureter coursing over its 
anterior face. It displaces the uterus laterally, and presses upon 
the bladder and rectum. The Fallopian tube is stretched over the 
cyst and the ovary thinned out, but the ovary can still be detected 
as a separate organ. 

The fluid contained is usually straw-coloured, limpid, and of 
low specific gravity (1.002). The cyst is lined by cubical or cylin- 
drical epithelium, often ciliated. The cysts are almost always 
monocystic, rarely multiple, have very thin walls, and are trans- 
lucent. Only occasionally are these growths papillomatous, in 
which case their contents may be blood-stained. They are of ex- 
ceedingly slow growth. 

Symptoms. — They are merely those of a mass pressing upon 
the pelvic organs and disturbing their functions, or even causing 
abdominal enlargement. There is no disturbance of the uterine 
functions. 

The diagnosis is based upon the presence of a tumour which is 
symmetrical, and upon palpation is very elastic and devoid of 
semisolid portions. Vaginal examination shows, as a rule, that 
the tumour is intraligamentous, sessile upon the uterus, dis- 
placing that organ laterally. 
136 



138 GYNAECOLOGY 

Treatment. — The tumour should be removed by laparotomy as 
soon as discovered, as its tendency is to grow and interfere with 
pregnancy, cause obstruction of the ureter, etc. Hanging from 
these and other tumours, as well as from the normal tube, may 
often be seen a small, thin-walled cyst attached near the fimbriated 
end of the tube. This is the hydatid of Morgagni which forms at 
the end of the longitudinal canal of the parovarium. It produces 
no symptoms and calls for no treatment. 

Hydrocele of the Round Ligament. — This is a sacculated serous 
accumulation under the peritonaeum of the round ligament. It is 
due to Alexander's and other operations on the ligament, or to un- 
known causes. It produces no symptoms. It is found accidentally 
when the abdomen is opened for other reasons, and is to be treated 
by merely evacuating the fluid and excising a portion of its peri- 
toneal sac. 

Ovarian Glandular Cyst. — It arises from the true ovarian 
stroma. It is always multilocular, or has been so. True ovarian 
cystoma, which appears unilocular, may, upon close examination 
of its interior, be found to present trabecular which are the remains 
of former partitions, or upon being inspected before a light will 
show secondary smaller cysts still in the main wall. The cyst is 
either proliferating glandular or proliferating papillary. 

Proliferating Glandular Cyst (Fig. 46). — This reaches an enor- 
mous size, frequently over 100 pounds. Owing to the aggressiveness 
of modern surgery and the diffusion of knowledge, they are usually 
discovered and removed now before reaching such a size. 

The tumour arises from the glandular portion of the ovary, 
not from the hilum. It is lined by cubical epithelium which, as 
the intracystic pressure increases, may become exfoliated, leaving 
the fibrous internal coat of the cavities bare of epithelium. The 
fluid contained in the cyst is of high specific gravity (1.020), ropy, 
and gelatinous. It may be clear, yellowish, claret-coloured, or 
greenish. Crystals of hasmatin and cholesterin are found, and 
the fluid contains much pseudo-mucin, a characteristic element. 
Pseud o-mucin is not found in the fluid of normal ovaries, in cystic 
ovaries, or in parovarian cysts. Occasionally it occurs in the fluid 
of papillary cysts. The growth of the cyst is due to proliferation 
of the lining epithelium and epithelial secretion. The tendency 
to ovarian cystoma is probably congenital. There is undoubtedly 
a tendency in the disease to occur bilaterally. 



TUMOUKS OF THE PAROVARIUM AND OVARY 139 

Papillomatous Ovarian Disease (Fig. 47). — This may assume 
the form of papillomatous growths on a glandular ovarian cys- 
toma; or papillomatous parovarian cystoma; or dropsy of a 




Fig. 46. — True Proliferating Glandular Ovarian Cystoma. 

Note the depressions between the clear cystic portions of the growth, representing the 
points of attachment of the partitions between the cysts. The mass weighed 65 pounds. 



Graafian follicle with papilloma; or papillary adeno-carcinoma ; 
or papillary acleno-sarcoma. The papillary growth occurs on 
the non-cystic as well as the cystic growths. The disease is 
bilateral in half of the cases. It is malignant, in that the 
papillomata have a tendency to become spread over the entire 
peritonaeum both by the solid parts of the growth and by means 
of any fluid which may escape from the cystic papillomata. In 
addition to this certain of the papillomata are true carcinomata 
and sarcomata. The papillomatous buds within a cyst have a 
thinning effect upon the cyst-wall, and in time may protrude 
through the wall and appear upon the surface of the growth. 
Papillomata have occurred along the track of a trocar puncture 
after tapping such a cyst; on the vulva after vaginal removal; 
and secondarily in the abdomen after laparotomy, even when 
the original tumour was not cancerous. 



140 GYNAECOLOGY 

Papillomatous cysts do not grow to the large size of glandular 
cystomata. The outcroppings in papillomata are made of an ar- 
borescent connective-tissue stroma covered by epithelium. The 
fluid contents of papillomatous cysts is usually dark-coloured from 
admixture of blood, and rarely contains pseudo-mucin. The cysts 
are usually multilocular, occasionally unilocular. The papilloma- 
tous cystomata spring from the hilum of the ovary or parovarium. 




Fig. 47. — Papillomatous Ovarian Cyst. 

The papillary growths from the body of the ovary occur within 
Graafian vesicles, which are dropsical, or in fibroid, carcinoma- 
tous, or sarcomatous degeneration. 

Symptoms. — There are no symptoms to distinguish papilloma- 
tous cysts from other cysts, or papillomatous solid tumours from 
other solid ovarian growths. When the papillomata have appeared 
upon the surface of the growth and invaded the peritonaeum, there 
is more ascites with the small papillomatous tumours than with 
the simple glandular growths. And when the peritoneal involve- 



TUMOURS OF THE PAROVARIUM AND OVARY 141 

ment has become pretty general, the papillomatous tumour is more 
fixed than would be a simple cyst of the same size. Papillomatous 
cysts grow a little more rapidly than do simple glandular cysts. 

Dermoid of the Ovary (Fig. 48).— This interesting tumour is a 
cystic growth which contains hair, integument, bone, teeth, mucous 




Fig. 48. — Ovarian Dermoid and Small Cyst of the Organ of Morgagni. 
The Fallopian tube. Hair. Cyst. Cartilage. 



membrane, one or all. Sweat glands, mammary tissue, rudiment- 
ary heart and larynx have also been found in dermoids. It arises 
from ectodermal inclusions in the ovarian stroma. The walls of 
the cyst vary in thickness, and are lined by squamous epithelium. 



142 GYNECOLOGY 

The contents are cheesy or oily in consistence, due to the admix- 
ture of fat and sebaceous matter. The tumour is monocystic, 
usually not over 7 inches in diameter, and generally unilateral. 
It evidently begins to grow before puberty, when the uterus lies on 
the bladder, hence, unlike ovarian growths which start after pu- 
berty, it is often anterior to the uterus. A striking and inexplica- 
ble tendency in such tumours is to cause peritonitis even when 
they are small. 

Symptoms. — As a rule, the cyst is firmer than a small ovarian 
cyst, and in about half of the cases lies in front of the uterus, 
while an ovarian cyst which is of size small enough to remain in 
the pelvis lies behind the uterus. There is also more pain and 
sensitiveness about dermoids than about other cystic tumours. 
Otherwise the symptoms are those of a pedunculate tumour at- 
tached to the uterine cornu. 

Symptoms of Glandular Ovarian Tumours. — Ovarian cysts may 
attain a certain size and remain quiescent for years, but their 
tendency is to continuously increase from their beginning. This 
is particularly noticeable with the malignant and papillomatous 
growths, and these also produce more ascites than the other types. 
As the tumour grows out of the pelvis it drags the bladder up, 
compresses the rectum and ureters, and forces the uterus against 
the bladder. After the growth leaves the pelvis because that cav- 
ity can no longer contain it, it encroaches upon the abdominal 
viscera. The anterior and lateral abdominal walls are made to 
bulge outward, the viscera are forced upward, and respiration and 
nutrition are interfered with. The abdomen becomes enormously 
distended while the depreciated general health induces emaciation. 
The growth may reach a weight of several hundred pounds. Pres- 
sure symptoms, such as oedema of the limbs, supervene, the dysp- 
noea becomes so great that the patient cannot lie down, broken rest 
and malnutrition bring the patient to a state which renders her 
liable to pneumonia, from which, or nephritis, or sheer exhaustion, 
she dies. In the case of malignant growths metastases may form 
in other viscera. Early in the history of glandular ovarian cysts 
amenorrhea in half the cases becomes a prominent symptom, and 
this is observed in the young as well as in those of middle life. 
It occurs before marked depreciation in general health ensues, and 
therefore can only be attributed to the influence of the growth 
upon the ovarian structure. It is found whether the growth be 



TUMOURS OF THE PAROVARIUM AND OVARY 143 

unilateral or upon both sides. Parovarian cysts do not pro- 
duce it. 

Diagnosis of Glandular Ovarian Cysts. — If the tumour be pel- 
vic it almost invariably and from the first occupies a position be- 
hind the uterus. As the tumour grows it lifts the uterus upward 
and forward, forcing the corpus uteri and bladder above the sym- 
physis and the cervix against the neck of the bladder. If the tu- 
mour be so small as to float free in the pelvic cavity, it will be felt 
to one side of the median line and will not displace the uterus. 
There is little difficulty in detecting an ovarian tumour which 
is pelvic in its associations. It is always pedunculate, easily mov- 
able unless inflamed, insensitive to pressure, and will vary in 
consistence from the elastic bag of water which characterizes small 
cysts to the dense semisolid character of a large multilocular cyst. 
The tumour can be moved independently of the uterus, is easily 
displaced downward, and can be lifted no farther upward than the 
length of its pedicle. No ovary is present upon the side occupied 
by the tumour. In cystic growths fluctuation can' always be elic- 
ited and elasticity detected. When the tumour has risen into the 
abdomen it drags the uterus upward, but does not pin it against 
the symphysis unless the tumour has a pelvic lobe. 

It may resemble ascites. In ascites, as the patient lies upon 
her back the sides of the belly sag and the anterior wall flattens, 
while with a tumour an eminence shows under the anterior abdom- 
inal wall. As the patient breathes deeply the abdominal walls may 
be seen to move over a tumour ; not so in ascites. The percussion 
note over a tumour is flat, while resonant areas extend over the 
abdomen enlarged by ascites. In ascites the lateral abdominal 
walls are flat, while in ovarian cyst they are resonant. Ascites is 
usually due to some renal, hepatic or cardiac disease the nature 
of which can be determined. Fluctuation may be elicited in ascites 
but disappears if the centre of the abdomen be pressed upon by 
the edge of an assistant's hand. Fluctuation persists even under 
pressure if the enlargement be due to an ovarian cyst. 

Pregnancy upon superficial examination simulates ovarian cys- 
toma. But the two conditions have in common but two symptoms, 
amenorrhea and abdominal enlargement. In ovarian cyst the 
uterus is small and readily mapped out, and none of the symptoms 
of pregnancy are present except amenorrhea. 

Ovarian cystoma is movable, while cysts of the broad ligament 



144 GYNECOLOGY 

and retro-peritoneal cysts are fixed. The passage of a catheter will 
eliminate an overdistended bladder as a cause for the enlarge- 
ment. 

A large cystic kidney may reach into the upper pelvis. But 
the plane of displacement of such a growth is upward towards the 
free ribs, while the plane of displacement, under pressure, of an 
ovarian cyst is downward towards the true pelvis. 

Faecal masses can be indented by the finger, and the depressions 
so made remain; they are less movable than an ovarian cyst, and 
are removed by cathartics and enemata. 

Caseous tubercular peritonitis, that form which produces a mass 
of agglutinated intestines, enlarged mesenteric glands, and ascitic 
fluid, simulates very closely an ovarian cystoma. But such a 
tumour mass is fixed. In tubercular peritonitis the evening tem- 
perature is usually elevated, the pulse rapid, and cheeks hectic. 
Tubercular peritonitis causes a thickening in the broad ligaments 
and fixes the uterus. There are evidences of pelvic peritonitis 
which are not present in ovarian cyst. Abdominal pain is a con- 
stant and marked symptom of peritonitis, and is only occasional 
in ovarian cyst. 

There is no difficulty in differentiating an ovarian cyst from 
hydrosalpinx, pyosalpinx, and other results of pelvic inflamma- 
tion. These are acute i3i origin and are more fixed than the small 
cysts with which they may be confused. If the woman be very 
fleshy the outlines of an ovarian cyst may be hidden. In such 
a case the vaginal and rectal examinations must be most thorough, 
if necessary assisted by general narcosis. The differentiation be- 
tween the various forms of ovarian cyst is, so far as it can be made, 
laid down under their several descriptions. 

Diagnosis of Solid Ovarian Tumors. — These simulate peduncu- 
late uterine fibroids, but are much more movable. The differen- 
tiation is difficult unless amenorrhcea is present. Ovarian sar- 
coma is of rapid growth, ovarian fibroma grows slowly. Neither 
produces uterine haemorrhages, but amenorrhcea, and ovarian sar- 
coma causes much pain. Ovarian fibroid produces no pain. 

If unable to make a positive diagnosis an exploratory incision 
may be made. On no account should the abdomen be punctured 
owing to the damage which might be done should the enlargement 
be due to pregnancy, or pus be present, or a papillomatous ovarian 
cyst or caseous tuberculosis. The exploratory incision does no 



TUMOURS OF THE PAROVARIUM AND OVARY 145 

harm in any case, and can readily be extended so as to allow 
of a complete operation if it be found that one is needed and 
is possible. 

Degenerative Changes. — An ovarian cyst is subject to degen- 
erative changes both in its sac and contents. The sac may become 
calcareous either in part or wholly, and at points in it may be 
seen remains of Graafian follicles and old corpora lutea. Haemor- 
rhages into the walls of large tumours are frequently found. 

Lastly, the cyst wall may be very (Edematous and even present 
spots of necrosis. The fluid contents in the cyst may be blood- 
stained from rupture of vessels in the trabecular or be purulent 
due to infection. A cyst may become attached to a knuckle of 
intestine and a false communication be established between the 
two. In that case the cyst will contain gases and faecal matter. 
Owing to inflammatory changes on the periphery of its sac, the 
cyst may become attached to any abdominal viscus, even the liver 
and stomach. 

If the pedicle of an ovarian cyst becomes suddenly twisted or 
strangulated the symptoms are rather acute. Either a haemorrhage 
into the sac of the tumour may occur and be large enough to cause 
great shock or even death., or the strangulation may be so complete 
as to produce gangrene in the tumour. The symptoms of this 
accident vary with the degree of the strangulation. There is usu- 
ally a sudden shock, accompanied by a most acute pain. The 
tumour suddenly becomes enlarged and tense and very sensitive. 
The patient may rally, but, as a rule, the lesions are progressive 
and either end fatally or are relieved by operation. The twisted 
pedicle has been known to become atrophied and the tumour be 
nourished by adhesions. Right-sided tumours rotate to the left, 
and tumours of the left ovary turn to the right. The cause of 
rotation is unknown. The changes which glandular ovarian cysts 
undergo have a most important clinical bearing. These changes 
are more often found in mature growths, occasionally in those 
of small size. Of all ovarian neoplasms we find that 27 per cent 
are either of a cancerous nature or of that malignant type which 
is clinically described as papillomatous. Therefore, the sooner 
an ovarian growth is surgically treated the better for the imme- 
diate and future condition of the patient. 

Occasionally a cyst will rupture, either because of a blow or 
spontaneously owing to weakening in its walls. Small ovarian 
10 



146 GYNAECOLOGY 

cysts and parovarian cysts often rupture without producing any 
symptom more disagreeable than a temporary shock, the fluid being 
absorbed. Kupture of a dermoid is usually rapidly fatal. Rupture 
of a papillomatous cyst results in a diffusion of its peculiar struc- 
ture over the entire peritoneal cavity and ultimate death from 
inanition. Ovarian glandular cysts when ruptured cause a limited 
or fatal degree of peritonitis according to the amount and char- 
acter of the fluid they pour out. Whenever the pedicle of a cyst 
becomes twisted or the cyst ruptures, an immediate operation is 
indicated. 

The relative frequency of the several varieties of ovarian tu- 
mour is represented in the following percentages: Adeno-cystoma, 
43 -f- per cent ; papilloma, 20 -f- per cent ; adeno-carcinoma, 6 -f- 
per cent ; sarcoma, 1 -f- per cent ; fibroma, 2 + P er cen t ; dermoid, 
19 + per cent; and parovarian, 7 -\- per cent. 

Treatment. — As soon as an ovarian cyst is discovered it .should 
be removed. On no account should a diagnostic aspiration be 
attempted in view of the possible malignant nature of the growth. 
If the tumour proves carcinomatous, papillomatous, or sarcoma- 
tous, the opposite ovary should be removed. It is the author's 
practice also to ablate the uterus in cases of carcinoma and sar- 
coma, unless the pedicle be long and free from malignancy. Small 
tumours which can be removed unruptured through the vagina 
may be so treated. Larger tumours are to be taken through the 
abdomen. In view of the possibility of papillomatous or 

OTHER FORM OF MALIGNANCY, OVARIAN TUMOURS SHOULD, IF POS- 
SIBLE, be removed without rupturing them. The increased 
length of incision to accomplish this in large 
<<*7 tumours is more than compensated for by 

the certainty that no fluid can enter the 
) peritoneal cavity, an accident hard to avoid 

when the tumours are tapped in situ for the 
purpose of reducing their bulk so as to pass 
„ ~ a small opening. If it is intended to tap 

£ IGr, ^fci/, "V'YST OF THE 

Corpus Luteum. Gen- the tumour, very large ones can be removed 

erally Cystic Ovary. through the vagina. 

Cyst of the Corpus Luteum (Fig. 49). — 
Occasionally a corpus luteum will not rupture and involute, but 
certain of its component parts will continue to grow. As a con- 
sequence, we have the ovarian stroma proper covering a yellow- 



TUMOURS OF THE PAROVARIUM AXD OVARY 147 

ish layer of wavy gelatinous material, and in the centre a blood- 
clot. The yellowish layer is loosely connected with the ovarian 
stroma. These cysts are perfectly innocent, and rarely reach a 
diameter greater than an inch. They cause much constant pain 
in the involved ovary, increase its size and weight, but do not 




Fig. 50. — Fibroma of the Ovaries. 

a, fibroid of the left ovary in section ; &, surface of the right ovarian fibroid ; c, fibroid of 
the right ovary in section ; d, surface of the left ovarian fibroid (Winckel). 



conduce to peritonitis. They are rarely discovered except dur- 
ing operations for other conditions. When found they do not 
call for the removal of the affected ovary. The periphery of 
the growth should be incised parallel with the long axis of the 
ovary, the yellow layer peeled out by mouse-tooth forceps, the 



148 GYNECOLOGY 

resultant loose flaps resected, and one or two interrupted sutures 
of fine tendon applied to approximate the edges. The opera- 
tion may be performed either through the abdomen or the vagina. 
I have observed that this condition is particularly common in 
women who have had post-partum or post-abortum sepsis of mild 
degree which resulted in pelvic peritonitis but no suppuration. 

Fibroma of the Ovary (Fig. 50). — This is a dense enlargement 
of the ovary characterized by the ingrowth of connective-tissue ele- 
ments which displace and smother the normal ovarian stroma. It 
is more a fibroid degeneration of the ovary than the formation of 
a distinct tumour. The growth looks like a sarcoma, but is mark- 
edly more firm. There is no pain, the growth is exceedingly slow, 
and the only local disturbance is the production of ascitic fluid 
in the pelvis. The tumour is either discovered accidentally or 
because the patient comes for advice regarding a movable " lump " 
in one iliac fossa. 

Varicocele. — The veins of the broad ligament may become enor- 
mously distended so as to form rounded knobs of blood sac which 
fill the lateral pelvic spaces. The condition is seen in a less degree 
in retroversion and subinvolution. The subjects of varicocele are 
usually women who are emaciated and suffer from enteroptosis. 
The symptoms are pelvic tenesmus, backache, and often a throbbing 
in the ovarian regions. Upon examination there can be felt upon 
each side of the uterus boggy, elastic, insensitive masses. These 
are increased in size when the patient stands and disappear when 
she is examined in the author's position. The operative treatment 
is by laparotomy. The ovarian vein should be ligated at the pelvic 
brim and again beneath the ovary and tube close to the side of the 
uterus. Care must be exercised not to include the artery in the 
ligatures. It is not necessary to remove the ovaries except when 
they are diseased, as the ligation causes obliteration of the veins. 

ECTOPIC GESTATION 

Ectopic or extra-uterine gestation is the fertilization and arrest 
of the ovum in its passage to the uterus. The ovum may continue 
to develop and produce a viable child or it may die and be absorbed, 
or the foetus having died, a lithopaedion may form, or the ovum 
may die but the ectopic placenta continue to grow for a time. 

The ectopic sac may form in that part of the tube which lies 



ECTOPIC GESTATION 



149 



within the uterine wall, constituting an interstitial pregnancy; or 
in the free portion of the Fallopian tube, constituting a tubal preg- 
nancy ; or it may form in the tube and escape between the folds of 
the broad ligament and form an intraligamentous pregnancy; or 
escape into the abdominal cavity and form an abdominal preg- 
nancy. Finally, the ovum may develop wholly within an ovary, an 
ovarian pregnancy; or be partly tubal and partly ovarian, tubo- 
ovarian pregnancy. The most common form is the tubal, and the 
most rare are the ovarian and intraligamentous. Next in fre- 
quency to the tubal are the abdominal forms. If the pregnancy is 
interstitial the ovum may be expelled into the uterine cavity and 
remain there to full term, while the placenta remains in the tube; 
or the ovum may die and the case behave as though the pregnancy 
was strictly tubal. If the pregnancy is tubal, the foetus may grow 
to become viable, or the sac may rupture between the folds of the 
broad ligament, or the tube abort into the peritoneal cavity. In the 
vast proportion of ectopic gestations, the foetus dies and becomes a 
foreign body. It is most likely to live if it escapes into the uterine 
cavity. A number of cases are reported where the foetus has 
escaped from the tube into the abdomen and remained viable 
for the full period 
of normal preg- 
nancy, or even 
longer. But one 
ovarian preg- 
nancy with a via- 
ble foetus has been 
reported, the case 
being the author's. 
In the earlier 
months all trace 
of the foetus may 
be lost; later in 
development it 
may be converted 
into a lithopaedion, or into adipocere; or the ectopic products of 
conception may form an abscess and empty into the bowel or the 
vagina. Not only is tubal pregnancy the most common type, but 
development of the sac is most usual in the outer half of the tube 
(Fig. 51). 




Fig. 51. 



-Unruptured Ectopic (Tubal) Gestation. 
The ectopic sac. The ovary- 



150 GYNAECOLOGY 

Wherever implanted the growth of the ectopic placenta has a 
thinning effect upon the enveloping structure, and there is always a 
tendency for perforation of the sac by the villi of the chorion. This 
is due to the fact that the maternal tissues contribute but little to 
the formation of the placenta : the ectopic placenta is almost 
wholly or fcetal origin. The maternal effort in this direction 
is limited to the uterine cavity, in which a decidua forms although 
the foetus is in the tube. The tubes are but slightly differenti- 
ated portions of the uterus, and the association of a tubal foetus 
and uterine decidua is not strange. It would appear that 

THE FURTHER FROM THE UTERUS THE ECTOPIC CONCEPTION OCCURS, 
THE LESS LIKELIHOOD OF A UTERINE DECIDUA. 

In the early weeks the tube containing the ovum is much more 
vascular than its fellow. Gentle pressure will cause the little nod- 
ule to glide back and forth in the tube. After a haemorrhage has 
taken place into the ectopic placenta or into the tube, the entire 
tube becomes of a livid hue. In the course of time, repeated intra- 
tubal haemorrhages having occurred, the tubal walls will become 
much thickened by laminated clots. 

Upon section the knife will pass through the spongy, blood- 
stained walls. The sac containing the foetus may appear exactly 
as does one of similar size in intra-uterine pregnancy ; or all traces 
of the foetus may be destroyed, and the mass be nothing more than a 
thick-walled sac composed externally of peritonaeum covering the 
thinned tubal wall which lies over the layers of fibrin and clots. 
Within these thick walls may be clotted or fluid blood. The case 
then presents as a hematosalpinx. Upon tearing the tissues apart 
under water, the villi may generally be seen to float up in a char- 
acteristic form. There are but two causes of haematosalpinx : tubal 
gestation and tubal papilloma; and as papilloma of the tube is 
exceedingly rare, we may say that nearly all cases of haematosal- 
pinx are due to tubal gestation. 

The lesions produced by advanced ectopic gestation, whether 
tubal or abdominal, are very many. As the placenta grows it 
reaches out and attaches to the bladder, side of the uterus, intes- 
tines, or pelvic wall. In consequence the vascular supply of the 
involved organs becomes enormously increased and the viscera dis- 
torted. 

If the pregnancy be ovarian, the sac will be composed at first 
of ovarian tissue only, afterward of ovarian tissue, the attached 



ECTOPIC GESTATION 151 

part of the Fallopian tube, and the broad ligament. But in ova- 
rian pregnancy at any stage, the placenta will be wholly within the 
sac, the ovarian ligament will be evident, and the Fallopian tnbe 
remain throughout its course as an elongated but distinct and un- 
invaded structure. Ovarian pregnancy simulates in appearance 
ovarian cyst or ovarian haematocele. 

2Etiology. — Ectopic gestation may be caused by any factor which 
will arrest the fecundated ovum in its passage to the uterus. The 
ovum may fall into a diverticulum in the tube; it may be stopped 
at a point of stricture which has been produced by an adhesion, 
flexure, or stenosis of the tube: but by far the greater number 

OF TUBAL GESTATIONS ARE DUE TO ADHESIONS WHICH BIND THE 
TUBE IN SUCH A WAY AS TO STOP ITS NORMAL PERISTALTIC ACTION. 

Salpingitis of a simple catarrhal type renders the tubal mucosa in 
a condition propitious to the occurrence of ectopic gestation, but 
the more usual and severe forms of salpingitis rather tend to 
prevent ectopic gestation. I have found most of my cases giving 
a history of mild sepsis after abortion or labour. It will be re- 
called that sepsis extends through the lymphatics and not pri- 
marily through the tubes, producing peritonitis rather than sal- 
pingitis. The lymph effusion seals the ovary to the tube and 
prevents tubal peristalsis. A large number of tubal gestations 
are seen to follow conservative operations upon the tubes and 
ovaries, it being probable that such operations lead to the forma- 
tion of adhesions, while at the same time opening the tube to the 
entrance of ova. Ectopic gestation may be multiple and may be 
repeated. It may also occur coincidently with uterine pregnancy. 
Symptoms. — The nearer the lodgment of the ovum is to 

THE UTERINE CAVITY, THE MORE CLOSELY WILL THE SYMPTOMS 

simulate normal pregnancy. Amenorrhea, anorexia, morning 
nausea are seen. But they may all be absent and the patient appear 
and feel in perfect health. In my experience, amenorrhea has 
been absent more often than present. Upon the onset of ectopic 
gestation, a true deciclua begins to form in the uterus. After a 
few weeks, usually, this is cast off, producing bleeding; and it is 
this irregular and abortion-like bleeding which I have found as 
the most frequent first symptom of ectopic gestation. And the 
nearer the gestation sac to the uterus the greater the development 
of the decidua and the more profuse the haemorrhage accompany- 
ing its discharge. But if the foetus does not die and the sac does 




152 GYNECOLOGY 

not rupture, the formation of a tumour will be noticed, quicken- 
ing be felt, and all the symptoms of normal pregnancy be experi- 
enced. Upon the death of the foetus all these will cease and a 
tumour remain; or, if the foetus dies in advanced ectopic gesta- 
tion, a spurious labour may set in. As a rule, some form of 
rupture of the sac takes place. Either the tube bursts, or the 

membranes rupture and the sac con- 
tents escape through the fimbriated end 
of the tube (Fig. 52). 

Pain is produced by even a partial 
rupture of the sac. This pain is severe, 
is of sudden onset, is lancinating, and 
unlike any pain previously felt. It 
is always accompanied by depression, 
and, if much blood is lost, collapse or 
sudden death may occur. The patient 

Fm. 52,-Ruptuked Ectopic while 0n the toilet > 0r in CoituS > 0r even 

(Tubal) Gestation. sitting still, may scream with the sud- 

den pain, and in a short time die. 
The sac may rupture and the blood escape in large quantities, pro- 
ducing all the symptoms of great shock ; or there may be a contin- 
uous slow dribble of blood and the system compensate for this for a 
long time before shock appears. The effusion of blood into the 
peritoneal cavity leads to the production of plastic lymph, and the 
presence of this lymph, as well as the absorption of the dead blood, 
gives rise to a slight toxaemia, with elevation in temperature. 
But fever is not a usual symptom of ectopic gestation. The symp- 
toms of pain and irregular bleeding may, after a time, cease, 
the ectopic sac and its contents wither and be converted into a 
mole, and the patient's health be restored. But such a fortunate 
result is unusual. As a rule the ectopic sac, after death of the 
ovum, either suppurates or continues to grow until it bursts. 

Unless relieved by surgical means all ectopic foetuses die and 
about 70 per cent of the mothers, a mortality to both foetus and 
mother not found in any other form of gestation under any other 
circumstances. 

The symptoms of tubal abortion are those accompanying the 
presence of the ectopic sac plus those due to a continuous loss of 
blood. These latter are a progressive anaemia and failure in 
strength, together with sharp stabbing pains in the affected tube. 



ECTOPIC GESTATION 153 

This pain is not due to tearing of tissue, but is caused by spas- 
modic contraction in the hypertrophied and infiltrated tissue of 
the tube. 

Examination. — The signs will vary with the seat of the sac and 
whether or not rupture has occurred. In tubal pregnancy before 
rupture there will be found a dense but elastic mass attached to 
one cornu of the uterus. It is usually not greater than of 3 inches 
diameter, is movable, is sessile upon the uterus, and is sensitive. 
If the examination be made at short intervals, the somewhat rapid 
growth may easily be appreciated. 

If the pregnancy is interstitial, the signs will be those of a 
fibroid situated at the uterine cornu, but rapidly growing. 

If the pregnancy is abdominal or ovarian, the signs will be 
those of an ovarian tumour. 

After rupture has taken place, the signs due to the presence of 
the foetus will be masked by those due to escape of blood, (a) If 
the blood has escaped suddenly into the abdominal cavity it will 
collect into a pool in the cul-de-sac. Its presence cannot at first 
be detected, because it remaius fluid for some days; but after it 
clots, the posterior vaginal fornix will bulge out and the protuber- 
ance will be boggy, elastic, and insensitive. After a week or so the 
blood will become encysted within the pelvis by the effusion of 
lymph, and now for the first time the uterus will become fixed, 
partly by the formation of fibrin within the clot and partly by 
plastic lymph. The escape of blood into the abdominal cavity 
constitutes an intraperitoneal limmatocele, and the condition very 
rarely arises from any lesion other than an ectopic gestation. A 
particularly vascular Graafian follicle will sometimes produce an 
ounce or two of blood which, upon operation, may be discovered, 
or blood may escape from a papillomatous ovarian growth, but 
beyond this I have met no condition except trauma which pro- 
duces pelvic haematocele. The blood clots very slowly and the 
clots are usually small. The slow clotting is due to the absence 
of air, and the fractional clotting is due to invasion by great num- 
bers of leucocytes. 

(b) If the blood escapes between the folds of the broad liga- 
ment it soon clots. Before clotting the signs will be those of an 
intraligamentous cyst: to one side of the uterus will be an elastic 
fluid accumulation which fills one side of the pelvis, displaces the 
uterus away from that side, lifts it up, and which is sessile upon 



154 GYNAECOLOGY 

the uterus. The uterus is slightly movable. After the blood has 
clotted the position of the uterus will be the same, but the mass 
sessile upon the uterus will be hard and inelastic, exactly simu- 
lating an intraligamentous fibroid. 

Diagnosis. — This is not easy before symptoms of haemorrhage 
arise. It is not the pain, the mass, the sensitiveness, nor the in- 
tra-uterine haemorrhage which alone points to the lesion. It is the 
careful consideration of the history of the case, accurate weighing 
of the value of each symptom, as well as their association, which 
makes the diagnosis possible. Tubal pregnancy and tubal abortion 
will simulate hydrosalpinx and cystic ovary. 

An ectopic sac ruptured between the folds of the broad liga- 
ment will simulate broad-ligament cyst and broad-ligament fibroid. 
Old pelvic haematocele, producing as it does fixity of the uterus, 
abundance of exudate, pelvic density and a low form of fever, may 
be mistaken for diffuse pelvic suppuration. Whenever there is any 
suspicion of ectopic gestation the posterior cul-de-sac should be 
opened and the diagnosis made clear. Vaginal section as a diag- 
nostic procedure is perfectly safe and argument for delay is no 
longer to be heeded. If posterior vaginal section has done no more, 
at least it has robbed ectopic gestation of many of its terrors. It 
is no longer necessary to wait for the pallor, the rapid pulse, the 
thirst, and other symptoms of haemorrhage before viewing the 
pelvic contents. The moment a mass is felt to one side of the 
uterus, and if there be the faintest suspicion of ectopic gestation, 
it is the surgeon's duty to at once clear up the diagnosis by an 
exploratory vaginal incision. The basis of this strong statement 
is that the earlier these cases are treated the greater the oppor- 
tunity for practising conservatism, and likewise the less the risk. 
Upon opening the posterior cul-de-sac a careful digital examina- 
tion is made of the pelvic contents. If there has been a recent 
haemorrhage dark fluid blood will escape. If there has been a 
haemorrhage some days past, small glistening clots will escape. 
An unruptured tube will be found of livid colour. It is exceed- 
ingly friable, and tears readily with rough handling. For the 
technique of this operation the reader is referred to the article 
on Exploratory Vaginal Section. 

Treatment. — There are two forms of ectopic gestation in which 
the treatment may be expectant: if the pregnancy be interstitial, 
there being sufficient tissue to prevent rupture and there being a 



ECTOPIC GESTATION 155 

possibility of the sac evolving towards the uterine cavity, a waiting 
policy is admissible; and in abdominal pregnancy if the foetus is 
known to be viable, operation may be postponed nntil a living child 
can be extracted. Both of these states are exceedingly rare, and 
therefore under only these most exceptional circumstances is delay 
warranted. The rule is, as soon as ectopic gestation is dis- 
covered, operate. There are two methods of operating : the vagi- 
nal and the abdominal. The vaginal incision should be made in all 
cases of pelvic haematocele, all cases of pelvic suppuration due to 
ectopic, and all cases of ectopic ruptured into the broad ligament. 
The author also prefers it in all cases except those in which the 
foetus is too large to pass the vaginal outlet. 

Abdominal section is undoubtedly indicated where there is a 
viable foetus, or a lithopgedion, or adipocere, or a large dead foetus. 
Inasmuch as not every one is familiar with the technique of vaginal 
section, or has the equipment for performing it, both operations 
will be described later. 



CHAPTEE VII 
UTERINE FIBROMATA AND FIBRO-MYOMATA 

These are commonly classed as " uterine fibroids." Of all 
uterine tumours they are the most common. They occur very 
rarely before the twentieth year of age and are seen most fre- 
quently between the ages of thirty-five and forty-five. They are 
more frequent in the negress than in the white woman. The 
origin of these tumours is not definitely determined. As a rule, 
they result from the growth of certain cells which have been caught 
within the uterine walls during the development of the uterus. 
They are therefore congenital in origin. These cellular " rests " 
may remain quiescent for years, and then, under the stimulation 
of pregnancy or endometritis or from unknown causes, may begin 
to develop. Being of structure identical with that of the uterine 
muscularis, in their growth they produce masses of tissue identical 
with that of the uterus. If this tissue remains pure in type, it 
forms a myomatous growth; if admixed with fibrous tissue, a 
fibro-myoma results; and if the muscular cells entirely disap- 
pear and connective tissue alone remains, the tumour is a fibro- 
ma. These growths are exceedingly capricious in their develop- 
ment. A nodule may be present and remain quiescent for years, 
then grow rapidly; or a tumour which has caused most disagree- 
able symptoms may apparently disappear. Under the influence, 
of menstruation and pregnancy, they tend to increase in size. 
After delivery they may involute with the uterus. The advent of 
the menopause tends for a brief period to hold them in check, but 
in the intramural type only. 

Fibromata of the uterus may undergo certain degenerative 
changes. They may become necrotic and slough, become cal- 
careous, undergo fatty degeneration, or become sarcomatous and 
even carcinomatous. The percentage of fibromata which become 
malignant or which are accompanied by carcinoma of other por- 
156 



UTERINE FIBROMATA AND FIBRO-MYOMATA 157 



^1 




tions of the uterus is not inconsiderable. The vessels in the tu- 
mour, particularly the veins, may become greatly and generally 
enlarged, constituting the rare 
telangiectatic fibroid. Or 
the lymph spaces between the ( fn ' \ 

muscular bundles may be- VjN 

come much distended and the \J^ - : , ^-r^__ T^\ 

entire tumour be converted S \ 

into a spongy mass — fibro- /y^-- - 

cystic tumour. As a rule, 
fibroids are hard, and when 
cut project from a distinct 
capsule. The fibroid may be 
situated in either the body 
of the uterus or in the cervix, 
uncommonly in the cervix. It 
may be within the uterine 
walls, and, if bulging into the 
cavity of the uterus, it is in- 
tramural and submucous, or if 
projecting somewhat towards 
the peritoneal cavity, intramural and subserous. It may lie be- 
neath the peritonaeum and be attached to the uterus by a distinct 
pedicle, pedunculate, or by a broad base, and be sessile. It may be 
intra-uterine, and either sessile or pedunculate. If projecting be- 
tween the folds of the broad ligament, it is intraligamentous, or 
if beneath the peritonaeum of the pelvic floor, it is retro-peritoneal. 
These clinical designations are not without value as indicating 
the regional importance of the growth. Under the impulse of 
the contraction of the uterine muscle, all intramural fibroids have 
a tendency to evolve towards either the uterine or peritoneal cavity. 
The fibroids may form attachments to adjacent organs, as the 
omentum, and become entirely separated from the uterus, being 
nourished by the vessels in the false adhesions. In their develop- 
ment fibroids may press upon a ureter and produce hydro-ureter, 
or obstruct the passage of urine from the bladder or faeces from 
the bowel. They may press upon the sciatic or obturator nerve, 
causing much neuralgic pain. When adherent to the intestine, a 
fibroid may become infected by migration of germs from the 
intestinal canal. 



Fig. 53. — Scheme of Uterine Fibro- 

MTOMATA. 

A, pedunculate subserous tumour ; B, B, ses- 
sile subserous tumours ; C, pedunculate sub- 
mucous tumour ; D, intramural tumour. 



UTERINE FIBROMATA AND FIBRO-MYOMATA 159 

Fibrolipomatous tumours are rarely single, the presence of 
one indicating the nidus of others, though these latter may be 
exceedingly small, even microscopic. Upon section, the fibroid 
is seen to contain connective tissue and muscular bundles, occa- 
sionally bits of utricular gland. It is in these latter that carcino- 
ma may develop. As the fibroid develops it becomes surrounded 
by a distinct fibrous capsule from which the growth is nourished; 
but sometimes the uterus is generally enlarged, all its walls being 
thickened by multiplication of its fibrous and muscular elements, 




Fig. 55. — The Same Specimen as Illestrated in Fig. 54, seen from below in oeder 
to show the enormous hypertrophy of the ovaries. 



constituting general uterine fibrosis. The nearer the fibroid is to 
the endometrium the greater the tendency to a thickening in the 
latter — hypertrophic endometritis. 

There is a marked tendency for fibromata to occur in families, 
and a further tendency for fibroids of the uterus to be associated 
with fibroids of the breast. The softer and more vascular a 
fibroid is the greater its tendency to grow. Very firm and par- 



160 GYNECOLOGY 

ticularly pure fibromata grow very slowly and often remain qui- 
escent after the menopause. 

The ovaries are always diseased to some extent in myoma. 
The most usual lesion is a hyperplastic change. Under pressure 
these enlarged ovaries take most fantastic forms. Any form of 
ovarian disease may occur with myomata. The cause of the hyper- 
plasia of the ovaries in myomata is not known, but the condition 
is well recognized. 

Symptoms. — As a rule, the patient notices a progressive in- 
crease in the amount of blood lost at the menses. There is also 
very generally more menstrual pain than is habitual. The monor- 
rhagia is due to the hypertrophy in the endometrium, which very 
commonly occurs in the presence of a myoma, and the dysmenor- 
rhea is caused by spasmodic contractions in the uterine muscle in 
its attempts to squeeze out the myoma, which is practically a for- 
eign body within the uterine walls. Sometimes the menses will 
have been normal and the patient will have a sudden severe haemor- 
rhage, either at a menstrual period or between the menses. When 
the menses have become progressively increased there will, after a 
time, be irregular bleedings. The bleeding is most pronounced 
with the submucous and intramural fibroids, and less marked with 
fibroids which are subperitoneal and with those which spring 
from the cervix. After the haemorrhages have reduced the pa- 
tient to a pallid myxcedematous state there may be for months an 
amenorrhoea, or at most a watery, blood-tinged discharge. The 
patient has little more blood to lose, and anaemia has so lowered 
the metabolic forces that the menstrual nisus is absent. The loss 
of blood is in no way dependent upon the size of the tumour. 
At first the blood lost is bright, and clots, but after a time is so 
lacking in fibrin as to remain pale and fluid. As a rule, there 
is no increase in the habitual leucorrhoea, but occasionally there 
is an excessive intermenstrual watery flow, especially in fibro- 
cystic cases. If there be a fibroid projecting into the uterine 
cavity it may superficially slough and give rise to a putrid dis- 
charge. 

Next to menorrhagia, pain is the most frequent first symptom 
of myoma. This may be spasmodic, expulsive, and occurring at 
or about the menses, occasionally between, and is like a labour 
pain. Or the pain may be due to pressure by a myomatous nodule 
upon a nerve. If the tumour is intraligamentous, it may press 



UTERINE FIBROMATA AND FIBRO-MYOMATA 161 

upon the obturator nerve and cause pain and disability in the hip. 
Or the pressure may be anterior upon the crural nerve, or pos- 
terior upon the sciatic. The pain is not continuous, and is entirely 
irregular in occurrence. Some patients complain also of a " bear- 
ing-down " pain, or dragging pains in the loins. 

The presence of an abdominal tumour is next in frequency as 
a first symptom. Naturally this is most often the case where the 
tumour is intramural or subperitoneal, and springing from the 
corpus uteri. 

Pressure symptoms are frequent. Tumours arising in the 
anterior wall, particularly if near the internal os, may produce 
d}^suria, ardor urinae, or retention of urine. Those which are 
retro-uterine press upon the bowel and produce difficult defecation, 
obstruction of the rectum, and haemorrhoids. In fact, the appear- 
ance of haemorrhoids in a nullipara with a history of menorrha- 




FlG. 



56. A FlBRO-MYOMA SPRINGING FROM THE ANTERIOR UTERINE WaLL, BENDING 

the Uterus Backward and lifting the Bladder into the Abdomen. 



gia has often led me to an examination which discovered a myo- 
ma. The lumen of the rectum may be so narrowed that the 
stools are rat-tail in form. 

Pressure upon the pelvic veins often produces varicose veins 
in the legs or in the vulva. 
11 



162 GYNECOLOGY 

Many patients complain of a severe vertex headache just pre- 
vious to a haemorrhage, while in the stage of anaemia headache 
is severe and frequent. (Edema of the limbs from obstructed 




Fig. 57. — A Fibro-myoma arising from the Posterior Wall of the Uterus, becom- 
ing IMPACTED IN THE PELVIS BENEATH THE PROMONTORY OF THE SACRUM AND 

forcing the cervix up against the pubic bone, causing compression of the 
Urethra and obstructing the Rectum. 



venous circulation is frequent, and in the anaemic stage is to be 
expected. Obstruction by pressure of a ureter is often found 
causing hydro-ureter, hydronephrosis, or pyonephrosis. 

The heart muscle undergoes interesting changes. These are 
of two kinds: the fatty degeneration and the brown degeneration. 
The greater the loss of blood the more likely is one or the other 
form to occur, especially with fibrocystic tumours. 

Fibro-myoma uteri is very often associated with complications. 
Pedunculate tumours are prone to contract adhesions, particularly 
to the omentum and colon. Very large tumours may become ad- 
herent to the spleen, stomach, or liver. Certain lesions of the ovary 
are often found with myofibroma, particularly hsematoma and in- 
terstitial hypertrophy. The Fallopian tubes show in many cases 
the changes due to infection: hydrosalpinx and pyosalpinx. A 
pedunculate fibroid may rotate on its pedicle sufficiently to cause 
strangulation, peritonitis, and sepsis. And this accident is always 
to be feared when pregnancy occurs in the presence of a pedun- 
culate fibroid. 

A fibroid may become infected from an adherent knuckle of 



UTERINE FIBROMATA AND FIBRO-MYQMATA 163 

gut, break down into pus, and this pus discharge into the intes- 
tinal canal, and faeces into the shell of the fibroid. 

As an intraligamentous fibroid develops it displaces the ureter, 
and this may lie beneath or across the capsule of the fibroid. 

Until haemorrhages occur most patients look well. Later a 
sickly pallor comes on, due partly to the loss of blood, partly to 
the effect of the tumour upon the digestion. 

Upon examination a great variety of signs may be elicited de- 
pending upon the size, location, and type of tumour. A fibroid 
springing from the posterior surface of the uterus will, as it grows, 
displace the uterus forward until, eventually, it will press the 
bladder against the symphysis or even tilt the uterus and bladder 
out of the pelvis. When such a nodule is small it can be felt 
posterior to the cervix as a hard body fixed to and sessile upon 
the uterus. 

If the fibroid is intraligamentous, it will immovably fix the 
uterus. The uterus will be displaced laterally away from the 



■uterus 




Fig. 58. — Multiple Fibrocystic Tumours of the Uterus. 
There are both cystic and solid portions. Abdominal ablation. 



fibroid. Such a nodule is hard, not sensitive, not fluctuating, 
and is sessile upon the uterus. If the fibroid is subperitoneal 
and pedunculate, it may move independently of the uterus; but its 



164 GYNECOLOGY 

association with the uterus is readily determined by shoving the 
fibroid upward, when the uterus will also move away from the 
finger in the vagina. 

Tumours which are intramural form a mass indistinguishable 
from the uterus. They are not fixed until the pelvis is filled, and 
are insensitive, points of value in differentiating them from in- 
flammatory lesions. Sometimes there will not be one predom- 
inating tumour, but the uterus will be studded with knobs in 
most of its periphery. 

Fluctuation cannot be elicited in fibromata or fibro-myomata, 
but is occasional in fibrocystic growths and in the rare telangiec- 
tatic tumours. 

The percussion note over fibroids is flat. 

Sometimes a vascular bruit is heard upon auscultation. 

Large tumours resting on the aorta may transmit the aortic 
sounds. 

Upon vaginal examination the cervix may be found gaping and 
admit the finger, presumptive of the presence of a myoma pro- 
jecting into the uterine cavity. 

The cervix may be displaced towards the pubes if the fibroid 
be retro-uterine. If springing from the anterior wall, it may 
displace the cervix downward and backward. 

Intraligamentous nodules push the cervix to the opposite side 
of the pelvis. 

Large fibroids above the uterus may push the organ entirely 
out of the vagina, and a myoma may escape from the cervix and 
by its weight invert the uterus. 

Rectal examination furnishes most valuable information re- 
garding the contour of the posterior wall of the uterus and the 
amount of pressure upon the rectum. 

Instrumentation is of little value in detecting a myoma. The 
speculum will show the state of the os externum, but often the 
cervix is so displaced that it cannot be seen. When it can be 
reached a probe passed into the cavity of the uterus will show the 
direction of its canal, but the uterine cavity may be so distorted 
that a probe cannot be passed. 

Differential Diagnosis. — If peritonitis has taken place about 
a fibroid, or if a pus focus has formed, the precise differentiation 
of the lesions may be impossible. A myomatous uterus may be 
interpreted to be a pregnant uterus, diffuse pelvic suppuration, 



UTERINE FIBROMATA AM) FIBRO-MYOMATA 165 

ruptured ectopic gestation, broad-ligament cyst, ovarian cyst, 
broad-ligament abscess, or pelvic exostosis. A myoma may exist 
with any of these conditions. 

From Pregnancy. — The pregnant uterus is soft, the fibroid 
hard. The cervix of the pregnant uterus is soft and tends to be 
open, that of the myomatous is firm. Amenorrhoea accompanies 
pregnancy, is exceptional in myoma. The pregnant uterus is 
symmetrically enlarged, while the myomatous is most often irregu- 
larly so. In pregnancy the vulva is cyanosed after the third 
month; in myoma, it may be varicosed, but is never cyanosed. 

From Pelvic Suppuration. — Diffuse suppuration gives a uterus 
fixed in a dense mass and fixed in the pelvis, so may myoma. 
Suppuration generally causes fever, sometimes not; myoma does 
not. Both cause menorrhagia. Fluctuation is present in pus, ab- 
sent in myoma. Emaciation is common in suppuration, but does 
not result from myoma. Chills are absent in myoma, frequent in 
suppuration. In suppuration are many characteristic symptoms 
and an early history entirely wanting in myoma. Pyogenic cocci 
are usual in cervix or vagina in suppuration, and occasional in 
myoma. Purulent leucorrhcea is usual in one, not in the other. 
Leucocytosis is present in suppuration, absent in myoma. Pep- 
tones occur in the urine in suppuration, not so in fibroma. 

From Ovarian Cyst. — Both may displace the uterus. Ovarian 
cyst does not cause menorrhagia, often produces amenorrhoea. 
An ovarian cyst is elastic and gives deep fluctuation; myoma may 
be elastic, but does not fluctuate. Ovarian cyst is movable, and 
independently so of the uterus, while the uterus moves with a 
myoma. A pedunculate fibroid may simulate a floating kidney, 
but the area of displacement of the fibroid is downward, that of 
the kidney upward. 

From Ectopic Gestation. — Both produce haemorrhages and a 
mass about the enlarged uterus. The confusion is chiefly with 
tumours which are intraligamentous. The fibroid is more dense 
than the clot and lymph resulting from ruptured ectopic. Tubal 
gestation is very sensitive, myoma is not. Fibroid produces pain, 
which comes on very gradually; the pain of ruptured ectopic is 
sharp, lancinating, and accompanied by severe shock. The haem- 
orrhage from the uterus in ectopic has not been preceded by 
others; on the contrar}', there is often antecedent amenorrhoea, 
while in myoma the menorrhagia is usually progressive. 



166 



GYNAECOLOGY 



Exostosis and enchondromata have no such histories as are 
furnished by fibromata. 

From Inversion of the Uterus. — In inversion the two orifices 
of the Fallopian tubes may be seen near the base of the mass, 




Fig. 59. — All Types of Fibro-myoma aee illustrated in this Specimen. 
The large pedunculate nodule had been diagnosticated as a floating kidney. The dis- 
tortion of the uterus is well shown. To the left of the cervix intraligamentous 
nodules are seen. Abdominal ablation. 



UTERINE FIBROMATA AND FIBRO-MYOMATA 167 



and above at the constricted neck of the tumour no entrance to 
a uterine cavity can be found. A fibroid protruding into the 
vagina shows no Fallopian orifices on its surface, and above at 
the pedicle there is always to be found an entrance into the uterus. 

Prognosis. — A myoma 
may slough and cause death 
from septicaemia, or a pus 
focus may form in an ovary 
or tube and rupture. Rarely 
does a patient with myoma 
bleed to death. The growth 
kills indirectly rather than 
directly, by so weakening the 
patient that some intercur- 
rent disease supervenes and 
destroys the patient. Dis- 
eases of the lungs, valvular 
lesions, degenerative changes 
in liver, spleen, and kidneys, 
are exceedingly common with 
myomata of long standing. 
In considering the propriety 
of any line of treatment, the 
complications which may re- 
sult if delay is permitted 
must be given due weight. 
Myoma has a marked influ- 
ence upon fertility and preg- 
nancy. Twenty-five per cent of myomatous women are sterile, and 
about 30 per cent miscarry. Myomata may entirely disappear, so 
far as we can discover from examination; but such a fortunate 
result is exceedingly rare, and is not to be considered in determin- 
ing a method of treatment. But more frequently myomata are 
extruded into the uterine cavity and expelled from the uterus. 

A MYOMA TENDS TO POSTPONE THE MENOPAUSE AND TO CAUSE 
A RECURRENCE OF THE BLEEDINGS EVEN AFTER THE CHANGE 
HAS ONCE OCCURRED. THE OCCURRENCE OF THE MENOPAUSE HAS 
LITTLE INFLUENCE ON THE GROWTH OF MYOMATA, AND AFTER 
THE CLIMACTERIC DEGENERATIVE CHANGES IN THE MYOMA AND 

complications are most numerous. The consideration, then, 




Fig. 60. — A Large Fibro-myoma of the 

Cervix (Roberts). 

The probe is passed into the cervical canal. 



168 GYNECOLOGY 

of an approaching climacteric furnishes no comfort to either 
physician or patient. Very few myomata become sarcomatous, but 
cancer in uteri, the seat of myomatous change, occurs with signifi- 
cant frequency. 

Not the least important result of myomata, which cause fre- 
quent and profuse haemorrhages, is a diminution in the coagula- 
bility of the blood; the time of clotting may be as much as 
fifteen minutes. 

Treatment. — Medical. — If a myoma is submucous, the admin- 
istration of ergot in large doses sufficient to produce uterine con- 
tractions tends to cause the tumour to become pedunculate and 
intra-uterine, when it may be removed through the cervix. Certain 
myomata are markedly influenced by the internal administration 
of thyreoid extract and mammary-gland extract, and this influence 
is most marked in tumours having little fibrous tissue in their 
composition. Pedunculate subperitoneal tumours and those which 
spring from the region of the cervix, as well as fibrocystic growths, 
are little influenced by these animal extracts.. In certain cases the 
results of this treatment are startling. When the administration 
of the drug is stopped, the tumours begin to grow again. This 
treatment is most efficacious if preceded by curettage. Certain 
patients cannot take thyreoid because of its effect upon the heart. 
Thyreoid is more effective than mammary gland in causing re- 
duction in a myoma. The drugs operate by causing absorption 
of the constituent parts of the growth. They further tend to 
check the haemorrhages accompanying the intramural myomata. 
Under this treatment a uterus which has repeatedly aborted may 
permit a full-term gestation. I have held tumours in abeyance 
for years with this treatment. The dried extracts are given in 
5-grain doses t. i. d. 

If a patient is seen during a haemorrhage and the bleeding is 
alarming, the cervix should be plugged with iodoform gauze and 
the vagina tamponed, or the uterus filled with gauze, or the cervix 
sewed up. The latter procedure requires no narcosis, and if done 
the sutures must be removed in three days lest the blood pent up 
in the uterus decompose. Electricity once advocated for fibroids 
is of little efficacy, and not without danger. 

Pedunculate subperitoneal myomata, pedunculate intra-uterine 
growths, retroperitoneal and intraligamentous growths are to be 
treated surgically only. 



UTERINE FIBROMATA AND FIBRO-MYOMATA 160 

The myomatous uterus may be subjected to removal of the 
tumours only, myomectomy ; or the uterus itself may be amputated 
at the cervix by laparotomy, partial hysterectomy; or the entire 
organ may be removed, ablation or total hysterectomy. Further- 
more, in certain cases these operations may be performed through 
the vagina, in certain others through the abdomen. 

Ligation of the uterine arteries by the vagina is of doubtful 
efficacy in causing arrest in growth of a myoma, as the collateral 
circulation with the ovarian arteries is too elaborate. 

Curettage has a marked influence upon the growth of intra- 
mural myomata, particularly if performed after delivery or mis- 
carriage. The general treatment of a myomatous case seeks the 
diminution in the loss of blood by confinement to bed during the 
menses and the administration of thyreoid or mammary extract, 
a generous diet with abundance of fluids, and iron preparations 
to overcome the anasmia. 

By xo means does the discovery of a myoma indicate a 

SURGICAL OPERATION. THE LOCATION OF THE GROWTH AND THE 
SYMPTOMS IT PRODUCES, AS WELL AS ITS SIZE, NOT ONLY WILL 
DETERMINE THE URGENCY OF SURGICAL INTERFERENCE, BUT WILL 
ALSO FAIRLY WELL DEFINE THE NATURE OF THE OPERATION. 



CHAPTER VIII 
CANCER 

Cancer occurs in the uterus more frequently than in any other 
part of the human body. It is undoubtedly increasing, and so 
rapidly in certain localities as to furnish to these the designation 
of " cancer zones." It is rare before the twenty-first year, and 
no case is reported of its occurrence before puberty. It is most 
common between forty and fifty. Advanced age is not exempt. 
It occurs in the cervix in about 90 per cent of all cases and in 
the body of the uterus in about 10 per cent. There are two types, 
the epithelial and glandular. 

The cause of cancer is unknown. There are two chief theories : 
Cohnheim's, which supposes cancer to be due to activity in epi- 
thelial " rests " of embryonic origin, and the parasitic hypothesis. 
The author inclines to Cohnheim's theory, though impressed by 
the arguments of those who seek to prove its parasitic origin. 

Age. — Epithelioma is most frequent between the ages of forty 
and forty-five, while adeno-carcinoma is most frequently seen be- 
fore forty years of age. Epithelioma is rare while the woman is 
bearing children, and usually begins after she has ceased; but 
adeno-carcinoma is not unusual during the childbearing period. 

Race. — It is less common in the negress than in the mulatto, 
and less in both than in the white race. The yellow races also 
have it. 

Heredity. — Whether the disease is inherited, or because mem- 
bers of a family live under the same environment, or because it 
is contagious, certain it is that in about 20 per cent of uterine can- 
cers other members of the families have had some form of cancer. 

The influence of irritation upon the genesis of cancer is not 
settled. We find that cancer of the cervix is rare in the nullip- 
arous, while the cervix through which children have passed is 
170 



CANCER 171 

prone to cancer. The same is true in other parts of the body: 
the soot-irritated scrotum of the chimney-sweep, the tongue and 
lip of the pipe-smoker, the breast once inflamed and lanced, etc., 
all show the influence of injury upon the proneness to cancer. 

CANCER OF THE CERVIX 

Epithelioma. — Squamous Cell. — This is the most frequent 
form. At first the cervix is nodular, with here and there little 
elevated papillae. The nodules are tense, feel hard but are easily 
torn, and bleed easily upon rough handling (Fig. 61). The papillae 
rapidly multiply and increase in length, crowd together, and pro- 
ject into the vagina as a fungating mass (Fig. 62). If we cut 
the cervix where this mass is attached, we find it pale in areas 
with darker striations. The latter are the fibrous bundles of 
the cervix, and the lighter tissue is composed of nests of epi- 
thelium which may often be squeezed out as pearl-like bodies. 
Not only is there epithelial proliferation, forming a growth out- 
ward, but also an epithelial invasion of the essential structure 
of the cervix. The ingrowth precedes the outgrowth. The super- 
ficial portions of the growth soon disintegrate, forming necrosed 
spots covered by blood and pus. This disintegration proceeds 
until the entire cauliflower-like mass melts away, leaving in place 
of the cervix, the contour of which may be partially or wholly 
lost, an excavating ulcer. The disease may involve the vagina 
adjacent to the cervix, or extend outward into the broad ligaments 
through the lymphatics, or involve the bladder and less frequently 
the rectum. As ulceration progresses, the corrosion may open 
into the bladder or rectum. As the broad ligament becomes in- 
filtrated, the ureter is pressed upon, resulting in hydro-ureter, with 
possibly pyonephrosis. Peritonitis and tubo-ovarian inflamma- 
tion are frequent lesions in advanced carcinoma. The squamous 
epithelium covers the vaginal face of the cervix and extends into 
the cervical canal but a short distance; hence this form of cancer 
is usually seen on the free surface of the cervix. 

Histologically the tissue is found to be composed of a pro- 
liferating connective tissue surrounded by many layers of squam- 
ous epithelium. The papillae of the outgrowths are pierced by 
delicate vessels which break easily. The connective tissue is sparse, 
while the epithelium is everywhere. 



11% 



GYNECOLOGY 



Adeno-carcinoma. — This may begin as a nodule which rapidly 
breaks down, forming a sloughing diverticulum of the cervical 
canal. The disease may begin at any point of the cervical canal. 




Fig. 61. — Squamous-cell Carcinoma, of the Cervix. (Natural size.) (Cullen.) 

Viewed from below. The cauliflower-like mass has been curetted away, but spring- 
ing from the enlarged and thickened cervix are delicate finger-like outgrowths, 
which in a few places have coalesced, forming smooth masses. The advancing 
margin of the growth is irregular, and appears to be sharply defined. At a, over 
an area 1 X 1.5 centimetres, is a slight elevation covered by very delicate knobs 
or finger-like projections. This specimen shows very well how the carcinoma may 
appear in the earliest stage. The cervical canal has been invaded for a short 
distance. 



The nearer it is seated to the external os the greater the involve- 
ment of the visible portion of the cervix. The disease also assumes 
the form of cauliflower excrescences within the cervical canal. The 
entire cervix may be excavated before the external os is implicated. 
One or both lips of the cervix may be involved. The epithelium 
of the old glands is multiplied, the stroma of the glands broken, 
and the periglandular tissue invaded by glandular epithelium. 
At the same time there is an enormous multiplication of glandular 
tissue with the characteristic proliferation of glandular epithelium 
(Fig. 63). 

As a rule, the glandular hypertrophy, proliferation, and ne- 



CANCER 



173 



crosis remain for a long time hidden within the cervical canal, but 
occasionally the disease will produce a cauliflower growth which 
will protrude into the vagina and appear as though springing 



from the vaginal face of the cervix. 




Fig. 62. — Squaaious-cell Carcinoma of the Cervix ; Cauliflower-like Mass 
springing from the Anterior Lip. ( 4 /s natural size.) (Cullen.) 

can be seen from the relative positions of the tubes and ovaries, the uterus has 
been opened posteriorly. Arising from the anterior lip is a large cauliflower mass. 
Its basal attachment is sharply defined, and the growth consists of myriads of 
delicate projections having rounded knob-like structures. There has been only 
slight breaking down of the cervix. The uterus is normal in size, and its mucosa 
is of the usual appearance. Both the tubes and ovaries are normal. The uterine 
arteries have been dissected out, tied off near their points of origin, and removed 
with the uterus. 



The growth of tissue may block the cervical canal and dam 
back the blood and secretion within the uterine cavity. This 



174 



GYNAECOLOGY 



becoming infected constitutes a " pyometra." Involvement of the 
bladder is more frequent with adeno-carcinoma of the cervix than 
with epithelioma, and of the rectum less frequent. The disease 
tends to extend downward and laterally into the broad ligaments. 




Fig. 63. — Adenocarcinoma of the Cervix. (Natural size.) (Cullen.) 

The uterus is opened anteriorly. The cervix is considerably enlarged, but its con- 
tour is well preserved. To the right, in the picture, there is slight loss of sub- 
stance in the tissue at the external os. At this point short finger-like processes 
are seen springing from the surface. Occupying the anterior wall just within 
the external os, continuous with the finger-like processes, and extending laterally 
to within a short distance of the broad-ligament attachment, is a new growth 
contrasting sharply with the normal tissue. The advancing margin of the 
growth, both along the cervical mucosa and in the substance of the cervix, is 
irregular. On the left side a section of the cervix has been removed, and the 
mode of extension is well shown, the processes of the growth penetrating into 
the healthy tissues, as the roots of a tree into the soil. The body of the uterus 
is slightly enlarged, its walls are of the usual thickness, but there is an increase 
of the blood-vessels throughout the muscle, great numbers being seen on cross- 
section projecting slightly from the surface. The arborescent appearance in the 
upper part of the cervix is well preserved. The endometrium is normal. Vagi- 
nal examination would have failed to give any adequate idea of the extent of 
the growth. 



CANCEK 175 

Pelvic inflammatory lesions are more common here than with 
the epithelial type of cancer, owing to the frequency of pyo- 
metra. 

Cancer of the cervix has a marked tendency to remain local- 
ized within the pelvis. It extends into the parametrium through 
the lymphatics, first reaching the glands opposite the obturator 
foramen, then the higher glandules hypogastrics about the bifur- 
cation of the common iliac artery. In advanced cases the inguinal 
glands also become involved. As the disease extends the rectum 
becomes surrounded by cancer nodules, the uterus fixed in the 
pelvis by cancerous infiltration of the broad ligaments, the bladder 
invaded, the ureters compressed, and the obturator and sciatic 
nerves pressed upon. The condition then becomes one of general 
pelvic carcinosis. 

Symptoms. — As a rule, the first symptom noticed, but one 
unfortunately which attracts little or no attention, is an increase 
in that leucorrhcea which the woman habitually has. This increase 
is slight in epithelioma, but in adeno-carcinoma of the cervical 
canal it is marked. This observation applies to the disease if oc- 
curring before the menopause. After the menopause the patient 
will observe a return of that long-forgotten leucorrhcea which she 
once had. This symptom, I find, occurs about four months before 
any other. It is important and is due to epithelial activity, upon 
which the secretion depends. 

In epithelioma, the next symptom is bleeding, or the escape 
of blood-stained discharge at irregular intervals. This is due to 
abrasion of the exceedingly friable epithelial proliferations, and 
may be produced by the slightest touch of the finger, by coitus, 
by douching, or by any force which will cause the cervix to rub 
against the vagina. The menses are not increased. 

The second symptom in adeno-carcinoma of the cervical canal 
is a foul, putrid discharge which is due to necrosis of the tis- 
sues. The canal being protected against injury, bleeding does 
not so soon occur, but the passage of a sound will readily develop 
it. This discharge also soon becomes blood-stained. 

The occurrence oe a bloody discharge or of a putrid dis- 
charge BETWEEN" NORMAL MENSES IS STRONG PRESUMPTIVE EVI- 
DENCE OF CANCER, AND AT LEAST ALWAYS DENOTES MOLECULAR 

death of tissue. These symptoms demand the most careful 
examinations. After cauliflower growths have formed there will 



176 GYNAECOLOGY 

be frequent, almost continuous, bloody discharges of foul odour, 
purulent or sanious. 

Pain is not a symptom of cancer of the cervix until pelvic 
involvement occurs with pressure on the nerves. Bloody urine 
and symptoms of cystitis occur as soon as the papillae penetrate 
the bladder mucosa. Anaemia and cachexia do not occur until the 
stage of ulceration is well advanced. 

The menstrual habit of the patient is not influenced. 

Nearly all cases of cancer of the cervix have had children. 
Fertility in women who have cancer of the cervix has long been 
noted. The disease is uncommon in the nulliparous. 

General Health. — Most patients with cancer of the cervix are 
in very good flesh. The appetite remains good and colour normal 
until ulceration has progressed quite far. Then a form of sec- 
ondary anaemia occurs which is described as " cancerous cachexia." 
As the pelvis becomes involved, the venous circulation is interfered 
with and oedema of the legs may occur, symptoms of cystitis 
supervene, obstruction to the flow of urine through the ureters 
with kidney lesions, and pressure upon the rectum with constipa- 
tion or haemorrhage if the cancer invades the lumen of the gut, 
are symptoms. The patient is utterly wretched in advanced cases. 
The sense of profound physical depression, the ever-present stench, 
and the symptoms arising from embarrassment to the functions 
of important organs, render the picture truly pathetic. Unfor- 
tunately, the mind remains clear to the last. 

The temperature is not elevated unless complications are pres- 
ent. The pulse is not influenced until the general health depre- 
ciates. It then becomes compressible and easily accelerated by 
exertion. 

Examination. — In cases of epithelioma the examining finger 
will, even in the early stages, cause bleeding. After a cauliflower 
mass protrudes into the vagina it is easily recognized as springing 
from the cervix. At first the uterus is perfectly movable and the 
pericervical tissues normally elastic, but soon after the growth 
begins to bud the tissues about the cervix become infiltrated. 
Still, large cauliflower growths may be present and the pericervical 
tissues be of normal consistence. The cancerous excrescence feels 
irregularly granular, unlike any other growth except condylo- 
mata. Digital exploration of the vagina in cancer of the cervix 
furnishes little indication of the nature of any nodule or out- 



CANCEK 177 

growth except that it bleeds very readily. Adeno-carcinoma of 
the cervical canal may be well advanced without indicating to the 
examining finger any sign of its presence. 

Very important evidence is to be obtained even in the earliest 
stages by the speculum and use of instruments. One characteristic 
of all forms of cancer of the cervix is its exceeding friability. 
Therefore, cancerous papillomata can be scraped off with the 
finger-nail; and the slightest touch of the sound, no matter how 
gently made, will cause adeno-carcinoma to bleed after budding 
has occurred. If the cervix is nodular and cancerous, the enlarge- 
ment may be grasped with a coarse tenaculum, and upon making 
traction the instrument will tear its way through, leaving granular 
and bleeding surfaces. Cancerous outgrowths are either not cov- 
ered by epithelium at all, or, if they are, the 'slightest touch will 
suffice to rub off these cells. If in doubt whether a nodule be 
an enlarged follicle or cellular infiltration, it may be punctured, 
and if cystic, glairy fluid will escape, while this will not occur if 
the nodule be cancerous. Cancer is not common where there is 
a very general cystic degeneration of the cervix, even though the 
cervix be much hypertrophied with the latter. If a cauliflower 
mass has formed its appearance is very characteristic. It is al- 
ways pedunculate, its surface denuded of epithelium and covered 
by a stinking pus and blood, and it is of a granular texture, being 
rough. If the tissue-necrosis has proceeded so far as to produce 
ulceration, there will be presented an excavated cervix, the opening 
being surrounded by an apparently healthy rim of cervical tissue, 
but the edges always tear easily when grasped by a tenaculum. 
The floor of the ulcer is nodular, covered by pus, and bleeds when 
touched. In some cases, particularly in old women, as the disease 
has occurred after the cervix has shrunk with the menopause, the 
vault of the vagina may be occupied by an irregular cicatrix some 
portion of which will be nodular or ulcerated. In such a case the 
nodules may feel hard, but are easily torn by a tenaculum. If 
a cancerous nodule is pressed upon by a sharp curette a consid- 
erable fragment will readily be removed. This is impossible with 
any other tissue. 

In adeno-carcinoma of the cervical canal the external os may 
appear perfectly normal, or a bud of cancer may protrude through 
it. In the nodular stage of this form of cancer the disease may 
be entirelv unsuspected even bv a skilled gynaecologist, and there 

h 



178 



GYNECOLOGY 



is no means of proving its existence before ulceration or budding 
begins. Fortunately this occurs early, and then the passage of 
the sound produces bleeding from the cervical canal. The normal 




Fig. 64. — Eversion of the Cervical Lips with Glandular Hypertrophy. (Cullen.) 
Upon superficial examination simulating epithelioma. Contrast with Fig. 61. 



cervical mucosa is very tough and does not bleed readily when 
touched. Whenever, then, the gentle introduction of the sound 
into the cervical canal produces bleeding, cancer is to be suspected. 
After necrosis of the infiltration has begun the cervical canal will 



CANCER 179 

be more or less hollowed out. It is surprising to what an extent 
this may proceed without there being evidence of the process 
upon the vaginal face of the cervix. If a small, sharp curette 
is introduced into the cervix a bit of the cancer can readily be 
removed. 

Diagnosis. — The cervical mucosa may extend downward so as 
to show as a reddened area about the os externum, or the torn 
cervix may be everted and the mucosa appear. Such a surface 
is raised, is never pedunculate, has sharply defined edges, is cov- 
ered by epithelium, and does not easily bleed; it may become 
inflamed, constituting a cervical folliculitis (Fig. 64). If caustic 
applications be made or violence inflicted upon such a condition, 
it may produce a true " erosion " with loss of substance, and the 
resultant ulcer may simulate a cancerous excavation; but beneath 
the ulcer of inflammation the tissues are firm, whereas the floor 
of a cancerous ulcer is exceedingly friable and can be dug out with 
any blunt instrument. In cystic degeneration of the hypertrophied 
cervix, the tissue between the cysts is firm and the punctured cysts 
evacuate their fluid contents. Neither feature is present where the 
nodules are cancerous. 

Condylomata of the cervix differ from epitheliomatous papillo- 
mata by being paler, firm, not bleeding when rubbed, and usually 
attached by a broad base. The condition is very rare. I have 
seen but one case, in a Syrian woman. The entire cervix was 
covered as well as the adjacent vagina. 

Syphilis of the cervix is very rare. The signs are those of 
similar lesions on other mucous membranes. 

Tubercular ulcer of the cervix is referred to in its proper place 
and will readily be differentiated from cancer. It is usually seen 
in general tuberculosis only (Fig- 65). 

Cervical polypi may cause irregular discharges of blood and 
foetid leucorrhoea. They are seen to spring from the cervical 
canal, are smooth, are not friable, may be single or multiple. 
They can hardly be mistaken for papillary adeno-carcinoma. Sub- 
mucous cervical fibroids are small and very dense. The overlying 
mucous membrane is normal — not so in cancer. 

The obscurity of the symptoms of cancer of the cervix and the 
indifference of women to the early symptoms is well shown by the 
fact that less than 15 per cent of all cases of cervical cancer that 
come to us admit of a radical operation, 85 per cent having pro- 



180 



GYNECOLOGY 



gressed too far before being discovered. Whenever in donbt re- 
garding the exact nature of a suspected cervix, a portion should 
be cut out and sent to the most competent authority accessi- 




Fig. 65. — Condylomata and Tuberculosis of the Cervix and Vaginal Vault. 
(Natural size.) (Cullen.) 
The entire cervix presents a rough, uneven appearance, due to coarse lobulations. Its 
outer margin is represented by an elevated ridge which also shows lobulations, 
while the vaginal vault surrounding it forms a secondary ridge in front and to the 
sides. On digital examination the projections were found to be very firm; they 
slipped easily under the finger and no bleeding followed the manipulation. 

ble. With a sharp scalpel a V-shaped piece of the cervix can be 
painlessly removed and a fine suture applied to close the 
wound, 



CANCER 181 

Prognosis. — Adenocarcinoma of the cervical canal runs a 
more rapid course and tends earlier to involve the lymphatics 
than does epithelioma. This may be due to the fact that the 
older women are more prone to epithelioma, and in them atrophic 
changes in the uterus and its lymphatics have taken place. The 
average of life in cancer of the cervix is less than two years. 
After the disease has extended to the parametrium, few cases 
live beyond eight months. Death is due to asthenia, some inter- 
current disease, or from sepsis. 

Pregnancy has a marked effect upon the progress of cancer, 
causing the disease to rapidly extend and producing in six months 
lesions not to be expected within a year. 

Treatment. — Cancer of the cervix may be treated by high am- 
putation and cautery, by caustics, by vaginal ablation, or by ab- 
dominal ablation. The medical treatment seeks the relief of pain 
by opiates. The stench is best overcome by a douche of Thiersch 
solution or by 1-per-cent formalin applications. The author has 
seen benefit from the internal administration of thyreoid extract, 
both in adeno-carcinoma and epithelioma. 

CANCER OF THE BODY OF THE UTERUS 

Very rarely is squamous cell epithelioma of the corpus uteri 
seen. This assumes the type of- an adeno-carcinoma. It may begin 
at any point within the internal os. The surface epithelium mul- 
tiplies, new connective-tissue filaments form, and the growth as- 
sumes a papillary form upon the surface of the endometrium. 
There next ensues an actual multiplication in the utricular glands. 
The cells lining the glands proliferate, the glandular stroma be- 
comes broken in places, and the epithelial cells invade the inter- 
glandular reticular tissue. The papillae continue to grow, and 
may remain as separate delicate processes or, uniting, form one 
large mass. The glandular or cellular proliferation invade^ the 
muscular coat also. After a time the superficial portion of the 
outgrowth dies and produces a pultaceous necrotic mass which 
may completely fill the uterine cavity. The uterus enlarges in 
all cases, and its walls may become so disintegrated by the cancer 
that the organ becomes elastic and feels like a bag filled with 
small grain. After a time the disease appears upon the surface 
of the organ and invades the upper folds of the broad ligament 



182 



GYNAECOLOGY 



and higher glandulce hypogastrics. Secondary metastases upon the 
vagina are occasionally seen. The disease has little tendency to 
extend downward, the internal os being its usual limit. The in- 
ternal os may be blocked by the growth, retention of discharges 
take place, and a pyometra form. In advanced cancer any one of 
the inflammatory lesions of the ovaries and tubes may be produced. 



A<J/,es,ons Ju 
to ^uspenzii 





Fig. 66. — Eaely Adenocarcinoma of the Body of the Uterus. ( 2 /3 natural size.) 

(Cullen.) 

The uterus is of the normal size and shape. Attached to the fundus are broad adhesions 
due to the suspension performed about one and a half years before. Connected with 
the adhesions are small masses of omental fat. The uterine walls are of the usual 
thickness, and contain two small myomatous nodules. The mucosa of the cervix, 
and of the greater portion of the cavity of the uterus, is normal. Springing, how- 
ever, from the fundus and posterior wall is a finely lobulated growth, which reaches 
nearly 1 centimetre in thickness, but does not appear to penetrate the uterine walls. 
This case is of great clinical interest, as the uterus had been examined from above, 
during the operation for removal of an ovary, seventeen months previous to the 
hysterectomy. Again, we know positively from microscopic examination that the 
carcinoma had existed more than seven months before the uterus was removed — • 
a fact which demonstrated the slowness of the growth. 



Inasmuch as cancer of the uterine body extends outward be- 
tween the upper and more elastic folds of the broad ligament an 
invasion of the tissues outside the uterus may take place without 
the fundus being fixed; whereas in cervical cancer fixity of the 



CANCER 183 

uterus is one of the first signs of the invasion of the parametrium. 
Furthermore, for some unknown reason, corporal cancer pro- 
gresses more slowly than cervical. Again, corporal cancer extends 
along the lymphatics of the round ligament, and in advanced cases 
invades the glands about the inguinal canal through which this 
ligament passes. 

Symptoms. — The first symptom noticed is usually a watery 
discharge of a most offensive odour. This odour is entirely unlike 
that of unclean genitalia, and is identical with that of rotting 
beef-tea. It irritates the parts over which it flows. This dis- 
charge soon becomes blood-tinged. Occasionally the first symptom 
is a sudden sharp haemorrhage. If the disease occurs during the 
menstrual life of the woman, the menses are increased. The nor- 
mal leucorrhcea is also increased, just as it is in adeno-carcinoma 
of the cervix and for the same reason; but in corporal cancer this 
increase is so slight as not to attract the woman's attention. As 
the disease progresses there is a continuous discharge of foul- 
smelling bloody discharge, often accompanied by the passage of 
clots and shreds of tissue. 

Carcinoma of the uterine body soon blocks the cervical canal, 
and hence the retention of the purulent blood causes septic mani- 
festations in the pelvic peritonaeum and adnexa much more often 
than in cervical cancer. The disease is most frequent after the 
menopause, after the forty-fifth year of age. Women at that 
time have ceased to have noticeable leucorrhcea and lose no blood. 
Therefore, the appearance of any discharge must put the 
woman on her guard, and if the discharge changes from a 
mucous to a watery character cancer is to be suspected. 
This suspicion becomes almost a certainty if the discharge 
becomes putrid and bloody. 

Pain is more frequent in corporal than in cervical cancer. At 
first it is of a sharp, lancinating character. If the flow is retained 
expulsive pains may ensue, and if infection occurs, the resulting 
inflammation causes the pain accompanying the complication. As 
a rule, there is at an early date a sense of heaviness about the 
uterus. In contrast with cancer of the cervix, women with cor- 
poral cancer are not only not prolific, but about 40 per cent 
are sterile. The general health of these patients remains good for 
a long time, but soon depreciates if the discharge becomes re- 
tained. The progress of corporal cancer is somewhat slower than 



184 GYNECOLOGY 

that of the cervix, probably due to the fact that it is most common 
after the menopause, when the absorbents have begun to undergo 
degenerative changes. 

Differential Diagnosis. — Several conditions may cause symp- 
toms similar to those produced by corporal cancer. Fibro-cystic 
disease of the uterus often causes a watery discharge, and the 
microscope only can determine the nature of the tissue removed 
by the curette. 

Sloughing mucous polypi may cause irregular bleedings and 
a putrid discharge, and again the microscope only can differen- 
tiate. If a curettage is done for purposes of diagnosis, it must 
be with the proviso that if cancer be found a radical operation 
shall follow within a month, for the trauma accompanying curet- 
tage opens up new channels for extension of the cancer. Too 
much stress cannot be laid upon the importance of resorting to 
the curette as a means for early diagnosis, and this simple opera- 
tion must cover the entire endometrium. If, however, the scrap- 
ings do not show cancer and the suspicious symptoms recur, it is 
well to remove the uterus, for in certain cases the cancer is situ- 
ated within the uterine muscularis and in others so high up in a 
lateral fornix that the curette misses it. The positive evidence 

FURNISHED BY THE CURETTE AND MICROSCOFE IS INFALLIBLE, BUT 
THE NEGATIVE BY NO MEANS SHOWS THAT CANCER DOES NOT EXIST. 

Treatment.— Cancer of the body of the uterus may be treated 
by either abdominal or vaginal hysterectomy, when a radical 
operation is indicated. In advanced cases, not admitting of re- 
moval, the uterus must be curetted and the cavity thoroughly 
cooked with the galvano-cautery. 

SARCOMA OF THE UTERUS 

This is rare. The disease may originate in either the endo- 
metrium or in the uterine wall. When occurring in the endo- 
metrium it presents as a smooth nodule or nodules simulating a 
submucous myoma. Later it may break down and present an 
ulcerated surface. Within the wails of the uterus sarcoma simu- 
lates intramural myoma. The type may be either round-cell or 
spindle-cell. The disease tends to extend outward between the 
folds of the broad ligament and through the uterus by continuity 
of tissue. It usually occurs before the menopause. 



CANCER 



185 



Symptoms. — While the tumour is in the nodular stage and 
before necrosis begins, the symptoms are those of fibro-myoma. 
After the growth has begun to break down carcinoma is suggested 



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Fig. 67. — A Bound-cell Sarcoma of the Body of the Uterus. (Natural size.) 

(Cullen.) 
The uterus is considerably enlarged and its walls are thickened. The cervix is intact ; 
its mucosa, as well as that lining the lower part of the uterine cavity, is normal in 
appearance. Occupying the greater part of the cavity is a new growth. This is 
sharply denned from the surrounding mucosa, and has springing from its surface 
delicate finger-like or polypoid outgrowths. It would be impossible, macroscopieally, 
to differentiate between this growth and an adeno-carcinoma of the body. 

by the symptoms. The uterus is generally much enlarged, movable 
unless fixed by extension of the sarcoma to the parametrium or 
by inflammatory exudate, and not sensitive. Neither by symptoms 



186 



GYNAECOLOGY 



nor examination can the diagnosis be made. It is not possible to 
differentiate without the use of the microscope. 

Treatment. — If the diagnosis of uterine sarcoma is made it 
calls for abdominal hysterectomy when the uterus is so enlarged 
that it cannot be removed en masse through the vagina ; but when 
this latter procedure is possible the vaginal route is preferable. 

Sarcoma of the cervix is exceedingly rare. It occurs in early 
womanhood. The type may be one of a bunch of grape-like bodies 
hanging from the cervix, rapidly extending and filling the vagina. 
These vesicular masses are filled by viscid fluid, are transparent 
and easily ruptured. Or the type may be one of an enlarged 
cervix which is nodular, the stroma being infiltrated by round 
cells. The disease in both forms tends to necrosis and the pro- 
duction of blood and sanious pus. Eapidity in growth will suffice 




disease 
lesions, 
readily 



for 

of 



the 
the 



Fig. 68. — Sarcoma of the Ovary. 
The growth was associated with multiple uter- 
ine fibroids. F, Fallopian tube; C, cystic 
portion of the sarcoma. The drawing very 
beautifully shows the medullary structure 
of the tumour. Vagino-abdominal ablation 
of uterus and tumours. 



to distinguish the 
from other cervical 
The microscope will 
confirm the suspicion. 
The disease calls 
abdominal removal 
uterus and upper third of the 
vagina, because when operat- 
ing through the vagina it is 
impossible to remove suffi- 
cient of the vagina and para- 
metrium. 



SARCOMA OF THE 
OVARY 



This may occur as a 
round- or spindle-cell infil- 
tration of the ovarian stro- 
ma, or there may be myxom- 
atous tissue mixed with the 
typical cells of sarcoma. The ovary is enlarged, highly vascu- 
lar, lobulated, and fractures easily upon rough handling. 

If the vessels which pervade the tumour are very numerous 
and enlarged the disease assumes the type of angeio-sarcoma. The 
tumour is of rapid growth and is usually seen during the child- 



CANCEE 187 

bearing period of life. In gross appearance the tumour may look 
like splenic tissue or brain tissue. Or it may be cystic. As a 
rule, the tumours are solid. The disease extends through the 
lymphatics and veins, and metastases are early found (Fig. 68). 

The symptoms are those of a rapidly growing solid ovarian 
tumour. But in sarcoma continuous dull pain in the affected 
organ is a pretty constant symptom and occurs early in the dis- 
ease. Ascites occurs early, and the uterus is prone to enlarge 
under the stimulus of the increased circulation attending the 
growth of the ovarian sarcoma. 

Treatment. — If the tumour is of small size it alone should be 
removed by the abdomen, the tube and ovarian ligament being 
ligated and cut away close to the uterine cornu, while the outside 
ligature on the ovarian artery should be at the pelvic brim. But 
if there be any doubt as to the ability to make the dissection 
wholly within normal tissue the uterus and opposite adnexa should 
also be removed by laparotomy, for the disease readily invades 
all tissues adjacent to its origin. 

DECIDUOMA MALIGNUM 

This is a malignant growth occurring during or after preg- 
nancy, occupying the placental site, and characterized by a tend- 
ency to become rapidly diffused by direct extension and through 
the agency of metastases. 

The growth probably arises from foetal structures. It is 
composed of an alveolar structure, the cavities rilled with blood 
and fibrin and not lined by endothelium. Between these spaces 
are cells resembling decidual cells and syncytium elements. The 
growth is of reddish colour, irregular form, exceedingly friable, 
and shows areas of necrosis. The uterine tissue surrounding it is 
usually infiltrated. Metastases in the lungs and vagina occur in 
over half the cases, while less frequent in other organs. The 
growth extends rapidly and tends to invade adjacent organs. It 
early necroses. 

Symptoms. — In about half of the cases the patient has recently 
aborted and discharged a hydatidiform mole. Kepeated and pro- 
fuse haemorrhages first occur and show that some grave lesion is 
present. This is soon followed by putrid and excoriating dis- 
charge and pelvic pain. The patient rapidly becomes anasmic, 



188 GYNECOLOGY 

septic phenomena or symptoms of lung involvement supervene, 
and death ensues within six months. The disease usually occurs 
within the post-abortum or post-partum month. Upon examina- 
tion the cervix is found enlarged and softened. In half the cases 
irregular nodular growths will be found upon the vulva or vagina. 
These are of rapid growth, of deep colour, very friable, and soon 
ulcerate. If the finger can be introduced into the uterus, the 
nodules may be felt and scraped off with the nail. In every case 
of hydatidiform mole this disease is to be suspected, and in every 
case of late post-partum haemorrhage it must be looked for. There- 
fore, a diagnostic curettage must always be done at once under 
both circumstances, for only by early diagnosis can the patient 
be saved. 

Treatment. — If the disease be limited to the uterus, abdominal 
hysterectomy should be performed (see Abdominal Hysterectomy 
in Cancer). In the inoperable cases all the physician can do is 
to relieve pain and employ local cleanliness. 



CHAPTER IX 
DILATATION OF THE CERVIX 

The cervix may be dilated for purposes of intra-uterine exam- 
ination or operation. There are two methods of dilating the 
cervix — the gradual and the forcible. Sometimes both must be 
employed, the forcible following the gradual method. 

Gradual dilatation of the cervix may be secured in a number 
of ways. For a long time gynaecologists have known that the 
cervix will soften and dilate around any foreign body which is 
left within it. If a filament of iodoform gauze is passed into the 
cervical canal and through the internal os, in twelve hours the 
cervix will be found more open and softened. Then a larger 
strip can be inserted and left in for a day. In this way each day 
inserting strips of gauze of increasing size, a dilatation of over 
a half inch in the diameter of the cervix can be secured. Through 
this the uterus can be packed with strong iodoform gauze in a 
case of endometritis, or it may be curetted. However, this method 
of gradual dilatation is employed generally in cases which need 
a curettage and cannot take ether. Very little pain is produced 
by it. 

The most usual method of gradual dilatation is by means of 
tents of laminaria or other material which swells when wet. In 
pre-antiseptic days this method was much used and was justly con- 
demned because it so often produced pelvic peritonitis. The tents 
can, however, be perfectly sterilized by dry heat. The patient 
should be in Sims's position, a nurse holding back the perinaeum 
with a short speculum. The operator draws down the cervix with 
a blunt bullet forceps hooked into its anterior lip. He then 
touches the entire cervical canal with pure carbolic acid and in- 
troduces into the canal a sterile laminaria tent which is well lubri- 
cated in boroglyceride. A snug tampon of iodoform gauze is 
placed in the vagina to hold the tent in place. In twelve hours 

189 



190 



GYNECOLOGY 




h 



the dressings are removed and the swollen and softened tent with- 
drawn. It will now be found possible to insert two tents into the 
cervical canal. These again are removed in twelve hours, the 
uterus washed out with bichloride-of-mercury solution (1 to 
10,000) and three tents inserted. When these are withdrawn in 
six hours, it will be found that the ringer can readily be introduced 

into the uterine cav- 
ity, and the uterus is 
prepared for the re- 
moval of intra-uterine 
growths. 

The treatment is 
painful and the pa- 
tient must be kept 
gently under the in- 
fluence of opium. 

Gynaecologists re- 
calling the destructive 
pelvic lesions formerly 
produced by the un- 
clean use of tents have 
apparently given them 
up entirely. Under 
our present precise 
methods of cleanli- 
ness, this valuable 
method of preparing 
the cervix for intra- 
uterine operations is 
perfectly safe. It 
should never be em- 
ployed in the presence 
of inflammatory ad- 
nexal disease nor when septic or gonorrhceic endometritis exists. 
The degree of dilatation secured by the use of tents is rarely de- 
manded except for the purpose of removing intra-uterine fibro- 
myomata. 

Forcible dilatation of the cervix is employed for the purpose 
of curetting the uterus and to enable the operator to reach the 
uterine cavity for other operative purposes. It is also employed 



Fig. 69. — Forcible Dilatation of the Cervix by 
Means of the Two-bladed Dilator. 



DILATATION OF THE CEEVIX 191 

by some to relieve dysmenorrhcea and sterility under the mistaken 
belief that the cervical obstruction causes both conditions. Dila- 
tation of the cervix a few days preceding menstruation undoubt- 
edly somewhat relieves that form of dysmenorrhea which is asso- 
ciated with anteflexion, and it does this because it produces a 
softening of the entire organ and causes a gradual flow of blood 
to the endometrium rather than the usual sudden congestion. 
But each month the procedure must be repeated to maintain even 
a slight relief. The procedure is objectionable in that it inflicts 
a trauma upon the uterus without the protection of technical 
cleanliness. The sterility for which dilatation is done is not due 
to closure of the cervix but to an abnormal endometrium. Sper- 
matozoa cannot only pass a cervical canal which easily admits 
a probe, but may also be found in the Fallopian tube the lumen 
of which is many times smaller than the most stenosed cervix. 
Lastly, other means are far more effective than dilatation in re- 
lieving dysmenorrhea, and are less harmful. Forcible dilatation 
for purposes of intra-uterine examination and operation is a valu- 
able aid to our operative technique. It should be done by means 
of a branched dilator, and may be preceded by gradual dilatation 
and accompanied by incision of the vaginal portion of the cervix 
in one or more directions. Some minutes should be consumed 
in the procedure, the full dilatation being secured by an inter- 
mitting pressure rather than one which is continuous. The cervix 
may often be opened by a combination of gradual and forcible 
dilatation to permit the removal through it of fibro-myomata of 
3 inches diameter, or at least to an extent which will permit the 
morcellation of intra-uterine growths of that size. 

CURETTAGE 

Indications. — Curettage of the uterus may be performed to 
remove an abnormal endometrium which causes dysmenorrhagia 
and sterility, to remove retained placental tufts, to induce involu- 
tion in the uterus, to check the bleeding due to nbro-myoma, to 
remove specimens for examination and diagnosis, and as an im- 
portant step in the operations performed for the various infec- 
tions of the uterus. The operation is best performed with the 
sharp curette of Sims. Only where isolated tufts of placenta have 
been retained is the dull curette indicated. The instruments 



192 GYNAECOLOGY 

needed are : 1 Jackson retractor, 1 Sims sound, a set of Sims' s 
curettes, blunt bullet forceps, uterine dilator, blunt straight bis- 
toury, tampon screw, dressing forceps, uterine packer, Fritsch- 
Bozeman irrigators, fountain syringe. Inasmuch as a raw surface 
is to be made within the uterine cavity, connected as the latter 
is with the peritoneal cavity by lymphatics and open Fallopian 
tubes, the most technical cleanliness is to be employed. To illus- 
trate how carelessly this most valuable operation is often per- 
formed, I am sure I have performed as many vaginal hysterec- 
tomies for pelvic pus due to unclean curettages as for lesions due 
to disease. If due care is exercised in its performance, curettage 
of the uterus is devoid of danger. 

The Operation (Fig. 69). — The patient is under general nar- 
cosis, and in the lithotomy posture. The perinseum is retracted 
and the cervix pulled down by bullet forceps, which an assistant 
holds. The direction and depth of the uterine canal are next de- 
termined by the sound. The cervix is then dilated. In perform- 
ing this important step of the operation a branched dilator should 
be employed, one which is opened by hand-squeeze alone and not 
by means of a screw. Unless such an instrument be used, the 
dilatation cannot be secured by intermittent force, as it should; 
and in case tearing begins in a cervix unsuspectedly friable, the 
force could not be released. The dilatation is obtained by turning 
the dilator a little from side to side as the hand is closed over 
the handles, so that all parts of the cervix may feel the force. 
Some minutes are needed for a proper dilatation if the cervical 
tissues be inelastic. The degree of dilatation will vary somewhat 
according to the disease for which the operation is done. If for 
sterility, a dilatation of at least -J an inch is necessary ; otherwise the 
cervical ganglia, upon which are dependent those uterine cramps of 
which some patients complain and which force out the packing, will 
not be prevented. As a rule, the dilatation must be proportionate 
to the size of the uterine cavity. It should always be sufficient to 
allow the passage of a large curette and irrigating tube in large 
uteri. If the cervix be stenosed it may be incised bilaterally. After 
the cervix is dilated the curette is introduced to the fundus and 
withdrawn in such a way that the cutting edge scrapes along the 
endometrium in a straight line. The blade of the instrument 
should be pressed hard against the endometrium, but the cervix 
must not be used as a fulcrum, The entire circumference of the 



CURETTAGE 



193 



cavity is gone over, particular attention being paid to the lateral 
angles and tubal openings. If the curette is introduced gently 
and the scraping done as described, there is no danger of going 
through the uterus, even if soft spots of necrosis be encountered. 
The depth to which the scraping shall penetrate will depend much 
upon the state of the uterus, and is determined by experience 
largely. In hard uteri, such as the sterile, the fibroid, and the 
old subinvoluted, a grating will be felt at all points from which 
the endometrium has been removed, and a spot producing this as 
the curette passes over it a second time is sufficiently scraped. 
But in cases of cancer, sepsis, in puerperal and other soft uteri, 
a nice touch alone will govern exactly the depth to which the 
scraping should proceed. 

As A RULE, THE SOFTER 
THE UTERUS THE LARGER 
SHOULD BE THE CURETTE, 

for perforation of the 
uterus is easiest where 
small curettes are used in 
large, soft uteri. 

After the curettage is 
finished, the next most 
essential step is removal 
of all debris and frag- 
ments of endometrium. 
In small uteri this is done 
by swabbing out the cav- 
ity with iodoform gauze, 
while in large cavities 
the swabbing is preceded 
by irrigation (Fig. 70). 

To swab out the cav- 
ity, a single thickness of 
a strip of gauze is laid 
over the blade of the cu- 
rette and introduced into 

the uterus. As the curette is moved across the uterine cavity the 
debris becomes caught in the gauze. Repetitions of this should be 
made until the gauze returns without showing fragments of tissue. 
When a large curette has been employed a large irrigator must be 
13 




Fig. 70.- 



-Irrigation of the Uteris with a 
Fritsch-Bozeman Tube. 



194 



GYNECOLOGY 




used, for large curettes produce large fragments. I employ the 
Fritsch-Bozeman double-current irrigator, the largest size of which 
has a diameter of f of an inch and is used in puerperal cases only. 
The sterile fountain syringe makes the best irrigating bag. Sev- 
eral quarts of sterile salt solution are allowed to pass through 
the irrigator. The uterus is again swabbed dry. I now, and 
invariably, pack the uterine cavity full of iodoform gauze. There 

are several reasons for 
this. It checks and 
catches all oozing. It 
furnishes an absolute 
protection to the cells 
while they are repro- 
ducing a new endome- 
trium, and when the 
lymphatics are invaded 
by germs of infection 
it undoubtedly drains. 
As the iodoform gauze 
is put up, it is in yard 
widths folded 9 times, 
and of 5-yard lengths. 
A piece cut across the 
length of the dressing 
will give, when un- 
folded, a strip of a 
yard length and of 
such width as the 
operator has chosen 
to cut it. A sterile 
uterus will receive 1 
yard of gauze 1 inch 
wide ; the full - term 
uterus will take a piece a yard wide and 5 yards long. Be- 
tween these two extremes the amount of dressing to be introduced 
varies according to the size of the uterine cavity. The cavity of 
the uterus is tightly packed and the filament passing through the 
cervix is loose. It is improper to pack the cavity loosely and plug 
the cervix tightly (Fig. 71). I introduce the gauze upon the point 
of a heavy applicator which has been curved to the canal, when the 



' ) 



A % 



"™* c -Jilii§> 









& 



w. 



Fig. 71. — Packing the Uterus with Iodoform Gauze 
by Means of a Heavy Applicator. 



CUKETTAGE 195 

uterus is small; but with large cavities and widely dilated cervices 
the gauze may be introduced either by tampon screw or long, 
narrow-bladed dressing forceps. The illustration shows the gauze 
being introduced into a uterus which had aborted at the second 
month. The uterine cavity being filled, the vagina is loosely 
packed with iodoform gauze. 

Experiments upon animals, as well as examination of uteri 
which had been curetted some weeks previous to a hysterectomy, 
show that not only is the endometrium completely reproduced in 
about four weeks, but that the new membrane is a histological 
structure. Although the operator may remove all the endometri- 
um down to the muscularis, the embryonic lymphoid structures 
will produce a new one. This reproduction needs no aid from 
us, only protection against injury, either chemical (as strong anti- 
septics) or bacterial. This protection is amply afforded by the 
non-irritating pack of iodoform gauze. And inasmuch as all other 
antiseptics are destructive of plasma cells, the operator should 
not, after curettage, paint the raw surfaces he creates with car- 
bolic acid, iodine, or other antiseptics. 

The intra-uterine packing is to be removed in two or three 
days, the shorter time in small uteri. 

It is not renewed in such cases, but the vagina is lightly re- 
packed and the patient allowed out of bed. In three days this 
dressing is removed. This is the last treatment. The first coitus 
is not before four weeks. When the curettage has been done on 
a uterus which is enlarged with a cavity of 5 or more inches, I 
occasionally introduce a second drain of gauze through the cervix 
to the fundus merely to prevent the cervix contracting too soon. 
This I always do if the operation has been done upon a uterus 
infected post-abortum or post-partum. But even in such cases 
the irrigation is not repeated unless the withdrawal of the first 
pack is followed by a large amount of pent-up bloody tenacious 
discharge. 

Another popular method of packing the uterus is through a 
cannula. This is useful when but partial dilatation has been em- 
ployed, but when the stretching is complete it is unnecessary. 

Certain operators employ a plug of hard rubber or glass, 
grooved or perforated for purposes of draining the uterus after 
curettage. Even were these superior to iodoform gauze as drains, 
I would advise against their use, because in about 65 per cent of 



196 GYNECOLOGY 

the cases we curette the cervical mucosa contains germs which are 
known to produce pus, notably gonococci, staphylococci, and colon 
bacilli. To connect this infected field with the recently curetted 
endometrium is to invite endometritis. In fact, it may be sur- 
mised that much of the discharge which the advocates of the 
draining plug proudly point to is due to a complicating infection, 
and that it is caused by the plug. 

In doing all after-dressings, the preferable position for the 
patient is' Sims' s, the perinseum being retracted by a short Sims 
speculum, and the urethral area so covered by the trowel that the 
dressings are not soiled when introduced. 

BILATERAL INCISION OF CERVIX 

Indications. — It is known that the normal cervical canal is 
a bilateral slit, sometimes curved. Contraction in this may take 
place at any point of the canal, most commonly at the os in- 
ternum. The older surgeons observed this and ascribed to it 
a multitude of ills, notably dysmenorrhea and sterility. Their 
methods of treatment demonstrated two things : namely, that dila- 
tation of the cervix with bilateral incision very often cured dys- 

menorrhoea, and that if the incised 
cervix be kept open even for a few 
days, the canal will permanently be 
of more normal dimensions. The 
scientific reason for these two indis- 
putable clinical findings is yet to be 
given. We accept the unexplained 
facts. Bilateral incision of the cer- 
V, vix is indicated whenever dilatation 
Fig. 72— Bilateral Incision of and curettage is performed in a case 
the Cervix. f simple anteflexion with stenosed 

The dotted line indicates the ex- cervix (see Fiff 25^ 
tent of the incision in the vagi- _ . ' ' 

nal face of the cervix. Operation (Fig. 72).— The sound 

determines the direction and contour 
of the cervical canal. The blunt-pointed, straight bistoury is intro- 
duced through the internal os, and this is incised upon each side 
just through the mucosa. As the knife is withdrawn the vaginal 
portion of the cervix is cut first upon one side, then upon the 
other, so as to make an incision two thirds of the cervical diam- 




INCISION OF CERVIX 



197 



eter. The gauze packing which is introduced after the curettage, 
tends to keep the cut edges apart, and the cervix never after closes 
as it was before. The operation is very similar in its effect to 
internal urethrotomy and is entirely devoid of risk. The incision 
may also be kept open by the cervical plug of Sims or the drain- 
age-plug of Wylie. Both are open to the many objections attach- 
ing to the use of the stem pessary, and are never employed by the 
author. 



ANTERO-POSTERIOR INCISION OF SIMS, MODIFIED 

Indications. — Whenever there exists anteflexion with retrover- 
sion and unequal enlargement of the portio vaginalis, the hyper- 
trophy of the posterior lip being less than 1|- inch, this opera- 
tion is indicated. If the hypertrophy be 
greater than this, either Dudley's operation 
or amputation is indicated. The operation 
is based upon the observation of Sims that 
if the posterior lip be incised and the inci- 
sion be kept open, the hypertrophied cervix 
will shrink, the uterine canal become more 
straight, and the uterus assume a higher 
and more anterior position in the pelvis. 

Operation (see Fig. 26). — The cervix 
is drawn down by a blunt bullet forceps 
hooked into its anterior lip. A blunt- 
pointed, straight bistoury is then inserted 




through the internal 



Fig. 73. — Method of ap- 
plying the Two Running 
Sutures after the In- 
cision is Made. 




that the internal os 
vaginal face of the 



Fig. 74. 



-The Completed 
Operation. 



os, its edge back- 
ward, and with- 
drawn in such a wa) 
is nicked while the 
cervix is cut through two thirds of its pos 
terior lip. The bistoury is then again in 
serted and the anterior border of the inter 
nal os is nicked. The uterus is now thor 



oughly dilated and curetted. The cut edges 
of the posterior lip would reunite if not separately sutured. To 
escape the use of Sims's stem pessary I have devised the method 
of suturing illustrated (Figs. 73 and 74). The suture material is 



198 



GYNECOLOGY 



preferably kangaroo tendon or chromic catgut. The intra-uterine 
gauze is removed in two days, and after that for a week only the 
vagina is kept packed with iodoform gauze. A new endometrium is 
reproduced in a month, after which coitus and the usual avocations 
of life are allowed. After this operation the cervix progressively 
shrinks, the dysmenorrhcea is relieved, the uterus assumes a higher 



.K 





First step. Removal of the section from the Last step. "Removal of the section from 
posterior lip of the cervix. the anterior lip of the cervix. 

Figs. 75 and 76. — Dudley's Operation for Anteflexion. 

position in the pelvis, and sterility is relieved in 60 per cent of 
the cases. During the first months of a succeeding pregnancy the 
nausea is much less than in cases of similar flexion not so treated. 



DUDLEY'S OPERATION FOR ANTEFLEXION 

Indications. — This operation is performed in the same class of 
cases as the last operation, but is particularly indicated where the 



DUDLEY'S OPERATION 199 

cervix is enlarged in all its diameters and associated with ante- 
flexion. 

Operation. — The cervix is incised through the posterior lip, 
just as in the modification of Sims's operation. From each raw 
surface so created a wedge-shaped piece is removed at about its mid- 
dle. The sutures are then passed as illustrated (Figs. 75 and 76). 
Now, from the anterior lip of the cervix an oval piece is cut and 
sutured bilaterally. This last step is not always necessary, only 
when the anterior lip is disproportionately enlarged. The benefits 
from this operation are still further substantiated if the uterus be 
thoroughly dilated and curetted at the same sitting. The operation 
occupies a position between my modification of Sims's procedure 
and amputation of the cervix. 

AMPUTATION OF THE CERVIX 

Indications. — This may be performed for hypertrophy, for 
laceration with hypertrophy, for inflammatory disease of the mu- 
cosa cervicis, to fold in the vaginal vault in prolapse, and to 
remove the portio vaginalis in other diseased conditions. There are 
two distinct types of amputation : one in which not only is a por- 
tion of the cervix removed but a new canal formed, and the other, 
the operation of Sims, which purposely avoids the creation of a new 
canal. 

The Amputation of Schroeder, Modified. — The cervix is incised 
bilaterally so as to create two flaps. The incision to effect this must 
proceed somewhat above the point at which the tissues are to be 
amputated (Fig. 77, A). The next step will depend a good deal 
upon whether the operation is performed for the purpose of re- 
moving a diseased cervical mucosa or hypertrophied tissue. We 
will assume that it is for hypertrophy with a general cystic 
degeneration and laceration. Upon the anterior flap and at 
right angles to the direction of the cervical canal, a transverse 
cut is made across the face of the flap to the depth of about J 
inch (Fig. 77, B). Another cut is made obliquely down through the 
tissues of the cervix to join this so as to remove a wedge-shaped piece 
(Fig. 77, C, and Fig. 78). The same procedures are gone through 
with the posterior lip. The centres of these two incisions upon the 
vaginal face of the cervix are now united to the cervical mucous 
membrane by 3 sutures of kangaroo upon each lip (Fig. 77, D, 






Fig. 77. 
The cervix has been split bilaterally so as to make two flaps. B. The amputation on 
the posterior flap is completed and is being done on the anterior. C. The scissors is 
shown cutting away the redundant portions of the bench. The knife is completing the 
amputation of the anterior flap. D. The new external os is completed, and through- 
and-through sutures are applied to close the angles. Cystic degeneration of the 
glands of the cervix is seen in A and B. These are removed by the operation. 
200 



AMPUTATION OF CERVIX 



201 




The shaded portions are cut away; 
d is to be united to e, and 6 to a. 



and Fig. 79) . There will thus be made both the anterior and poste- 
rior lips of the new external os (Fig. 77, D) . It will now be found 
that upon each side of this new os externum there are 4 knobs of 
tissue, and these are cut away with scissors (Fig. 77, C) so as to 
produce the appearance of Fig. 
77, D. The resultant raw sur- 
faces are now united by through- 
and-through sutures. If there is 
much tension, or if the operation 
is performed as a step in the se- 
ries of plastic operations for the 
relief of prolapse of the uterus, it 
is well to have the sutures next 
the cervical canal of 26 silver 
wire. Otherwise all sutures may 
be of absorbable material. The 
complete operation is shown in 
Fig. 80. The advantage oe this 
operation over trachelorrha- 
phy IS THAT IT XOT ONLY MAKES 

A CERVICAL CANAL MORE NEARLY NORMAL, BUT IT ALSO ENABLES 
THE OPERATOR TO REMOVE ALL THE DISEASED TISSUES OF THE CER- 
VIX, WHETHER OF THE PORTIO VAGINALIS OR OF ITS CANAL. If the 

cervical mucosa be particularly diseased, as in polypoid degenera- 
tion, the transverse incision across the 
cervical canal may be made high up, 
while the oblique cut to join this from 
the vaginal face of the cervix may be 
made correspondingly low down. And 
the operation may be modified so as to 
spare most of the cervical mucosa and 
remove a maximum amount of the 
portio. The operation is applicable 
to all forms of cervical hypertrophy, 
whether in the virgin or in the mul- 
tiparous. If dilatation and curettage 
are done at the same sitting, these steps should precede the ampu- 
tation. This operation should never be performed where a 

PURULENT ENDOMETRITIS EXISTS OR IN THE PRESENCE OF ADNEXAL 

disease. To do otherwise is to invite suppuration in the line of 




Fig. 79. — Showing Method of 

FORMING THE NEW ExTEEXAL Os. 



202 



GYNAECOLOGY 



suture and retention within the uterus of infectious products in the 
first instance, and is to run the risk of lighting up latent adnexal 
inflammation in the latter. 




Fig. 80. — The Completed Operation. 



TRACHELORRHAPHY 

Indications. — This operation may be performed whenever the 
cervix is lacerated. As the operation necessitates preservation of 
a" strip of cervical mucosa throughout its length, it must leave 
such glands in this as are diseased and such cysts as lie beneath 
this strip of mucosa. Furthermore, it forms a cervix which is 
conical and a canal which is too long and circular. The opera- 
tion once popular is now little employed, having been almost wholly 
supplanted by the amputation just described. 



AMPUTATION OF CERVIX 



203 



Operation (Fig. 81). — Upon each side of the cervical canal a 
piece of tissue half-moon in shape is removed. This may be done 
either with knife or scissors. If 
the laceration is unilateral, this 
piece of tissue is removed upon 
the side of the tear only. The de- 
nudation should proceed so deeply 
at the angles of the laceration (if 
this be bilateral) that the dense 
tissue usually there is removed, 
and the denudation must be so 
shaped in all its dimensions as 'to 
permit easy approximation of the 
raw surfaces created. There must 
be no rolling in or straining of 
the approximated surfaces. The 
sutures are to be applied as in the 
illustration. The suture material 
may be of silver wire or of absorb- 
able material. There are the same 
contra-indications here as in am- 
putation of the cervix. If cysts 
are met with, they should be punc- 
tured. The bleeding caused by the operation is slight and is 
controlled by the sutures. 




Fig. 81. — Trachelorrhaphy. 
Notice how the operation leaves the 
diseased glands beneath the central 
strip of cervical mucosa. 



THE CONICAL AMPUTATION OF SIMS 

Indications. — This operation is performed for one condition 
only, cancer of the cervix, and then only when the local lesions 
and general physical state of the patient exclude the propriety of 
a radical operation. It may be done either with knife and scissors, 
followed by the actual cautery, or by cautery knife. 

Operation. — The two lips of the cervix are seized by bullet for- 
ceps. The knife is entered upon the anterior face of the cervix 
at the cervico-vaginal juncture. By means of a sawing motion 
a cone-shaped piece of cervix is removed so as to include the 
internal os or extend even higher up inside the uterus. After 
all appreciable portions of the cervix are removed the uterus is 
curetted, and the entire inside of the organ is thoroughly cooked 



204 GYNECOLOGY 

by the galvano-cautery. The endometrium must be entirely de- 
stroyed so as, if possible, to prevent menstruation; otherwise the 
seat of the cervical amputation would lock in uterine discharges 
when the scar contracts. The operation may be further extended 
by dissecting up the pericervical tissues so as to expose the higher 
portions of the cervix and admit of their amputation. The oozing 
surfaces should be packed with iodoform gauze, which may be 
removed in two days, after which daily douches of mild antiseptics 
are given. When the slough due to the cautery separates, the 
wound may be further cauterized or allowed to close, according 
to indications. If during the operation a spouting arterial trunk 
is exposed, it may be choked bypassing around it, by means of 
a curved needle, a stout wire or silk ligature. 



CHAPTEE X 
PERINEORRHAPHY 

The Immediate Operation. — So soon as the placenta is deliv- 
ered and the uterus has firmly contracted, the torn perinasum 
should be repaired. The vulval tissues after delivery are deeply 
coloured, swollen, and exceedingly friable. It is wise to wait a 
few hours before suturing the wound while the oedema sub- 
sides, during which the operator can prepare for the operation, 
the torn surfaces in the meantime being covered by sterilized 
gauze. If the tear be only through the superficial muscles sterile 
cocaine of 4-per-cent strength may be laid over the raw surfaces 
for a few minutes before passing the sutures of fine tendon. These 
should not pass just beneath the raw surface, but should have a 
firm hold of all the tissues which have retracted. 

In more extensive tears, particularly if through the sphincter 
ani muscle, a more elaborate system of suturing is necessary. 
There is little retraction of the muscles as yet, and the tension 
is not great; therefore, in complete lacerations, tendon sutures 
will suffice throughout. But when the bowel has been entered, 
the wound at once becomes infected and a serious complication 
is presented. Under chloroform, a running suture of fine tendon 
is used to bring together the margins of the rectal and anal 
mucous coats. This effectively closes the bowel. The wound is 
then irrigated with sterile saline solution and wiped with gauze 
until every particle of filth has been removed. The vaginal rent 
is then closed by interrupted tendon sutures, each suture being 
tied as passed. Upon reaching the sphincter I bring together its 
edges by means of Xo. 27 silver wire, care being taken to so apply 
the lower suture that no dead space will be between the sphincter 
and bottom of the rent in the perinaeum. The wound should be 
kept irrigated with saturated solution of boric acid. For three 
days after the operation the patient should be kept on liquid diet. 

205 



206 



GYNECOLOGY 



On the fourth night a full dose of castor oil should be given. 
This laxative more than any other softens and lubricates the hard 
scybalous masses. The wire sutures are removed in two weeks. 

Incomplete Lac- 
eration. — CoIjjo- 
perinceorrhaphy 
(Fig. 82).— Inas- 
much as the oper- 
ation will produce 
a fixation of the 
tissues overlying 
the rectum, the 
bowels should be 
thoroughly evacu- 
ated the day pre- 
vious to the opera- 
tion, and only such 
food given as will 
produce little fae- 
ces. To allow the 
bowels to contain 
large scybalous 
masses which will 
pass to and distend 
the rectum and be 
forced out during 
the convalescence 
invites failure of 
union between the 
raw surfaces which 
have been approx- 
imated over the 
rectum. The local 
cleanliness is that 
which precedes a 
vaginal section. The patient is preferably in the lithotomy pos- 
ture, the operator comfortably seated at her buttocks. At a point 
upon each side of the vulva where the margins of the hymen merge 
into the vaginal wall a small piece of tissue is snipped off with scis- 
sors. Assistants then draw open the vulva and the operator de- 







— - 


- ^%0^ 




"n^^ 


J 

Mi 








' 


r} ^jyu/ 


1 • 






•■ .- _ j ', - 


■ '"■ . 


■^^^j'-. 



Fig. 82. — Incomplete Laceration of the Fekinjeum. 

Opposite the middle finger of each hand the " angles " or 
retracted fibres of the levator ani muscle and fascia are 
seen, covered by corrugated false vaginal tissue. Be- 
tween these angles is seen a protrusion, the " rectocele," 
formed by vaginal and rectal tissues. Above this the 
prolapsed urethra and bladder are seen forming a " cys- 
tocele." 



PERINEORRHAPHY 



207 



presses the perinseum with his fingers so as to expose the " crest " 
of the perinseum upon the posterior vaginal wall. He snips off a 
bit of tissue at this point. Straight lines drawn from the central 
denuded spot up in the vagina to the lateral marks on the vulva 
should pass above or external to the retracted lateral angles. If 
such straight lines pass below or through the lateral retracted 
angles, the marked spots upon the sides of the vulva must be made 
higher up or the straight lines be made to curve outward and up- 
ward. A narrow strip of tissue is now removed along the posterior 
muco-cutaneous border of 
the vulva so as to connect 
the two lateral marks (Fig. 
83). Or, the operator may 
now pass two fingers of the 
left hand into the rectum 
and draw the rectocele for- 
ward so as to expose the 
denuded spot over the crest 
of the perineum, and while 
assistants widely draw apart 
the vulval edges, he lightly 
marks with a scalpel the 
lateral borders of his in- 
tended denudation. After 
this all cutting is done with 
short, blunt-pointed scis- 
sors, curved on the flat 
(Fig. 84). The vaginal 
skin is removed in narrow 
strips until a raw surface is produced which corresponds 
to the demarcations already made. In removing these strips 
of tissue the two fingers in the rectum will be found of in- 
estimable service not only by furnishing a firm point against 
which to press, but also in estimating the thickness of the tissues 
between the fingers and scissors and in drawing out the lateral 
retracted angles. Throughout the operation an assistant plays a 
continuous spray of sterile saline solution over the wound. With- 
out removing his fingers from the rectum the sutures are passed. 
Here again the fingers are valuable aids in preventing puncture 
of the rectal mucosa. The first suture is passed near the crest of 




Fig. 83. — The First Step in Denudation for 

colpo-perin.£orrhaphy. 

The white lines indicate the boundaries of the 

denudation in the vagina. 



208 



GYNECOLOGY 



the denudation, and should be of fine tendon. The sutures are of 
chromic tendon and are a little over \ of an inch apart. Each is 
entered near the edge of the wound and is passed obliquely from 
above downward and inward to the median line, then upward and 
outward, to emerge opposite its point of entrance (Fig. 85). 
Each suture as passed is taken in charge by an assistant, who 
holds it upward out of the operator's way. When the retracted 
angles are reached the sutures are of No. 27 silver wire and are 

passed upon a carrier. These 
sutures must approximate the 
separated fibres of the levator 
ani muscle and its fascia. They 
are f of an inch apart and are 
passed in the following man- 
ner : the needle is entered at 
the edge of the denudation 
and pushed deeply enough into 
the tissues be- 
neath the retract- 
ed angle to secure 
a firm grasp of 
the levator fascia 
and muscle. As 
the operator turns the needle 
so as to point towards the me- 
dian line, he will feel the re- 
sistance furnished by the mus- 
cle and fascia lying over the 
needle; and if he does not, 
he will know the needle has 
missed the structures he wishes 
to approximate. As he turns 
the needle towards the middle 
he makes it pass downward 
and inward, not straight across. The needle is withdrawn at the 
centre and reintroduced beneath the denudation. It is then forced 
upward and outward, to emerge at the margin of the wound 
opposite its point of entrance. The utmost care must be exercised 
not to miss the tissues above the retracted angles, and the needle 
must be entirely buried beneath the angles as it passes. 




Fig. 84. — Showing the Manner of draw- 
ing THE KeCTOCELE AND VAGINAL ANGLES 

Forward by Means of Two Fingers in- 
serted into the Rectum, so as to facili- 
tate Denudation. 



PERINEORRHAPHY 



209 



The needles are brought out at the centre merely because they 
cannot pass entirely across the denudation in the proper direc- 
tion, which is that of an angle the apex of which is at the centre. 
Scarcely more than 3 
wire sutures will be need- 
ed within the vagina. 
As each carrying thread 
is passed, it is made to 
draw after it a silver- 
wire suture. If the 

NEEDLES ARE NOT PASSED 
AS DESCRIBED, BUT ARE 
MERELY MADE TO TRAVEL 
ACROSS FROM SIDE TO 
SIDE BENEATH THE DEN- 
UDATION, THE RECTOCELE 
WILL NOT BE LIFTED 
UP NOR THE RETRACTED 
LEVATOR FIBRES PULLED 
DOWN AS THEY SHOULD 

be. Still maintaining 
the same distances be- 
tween the sutures, the 
last within the vagina 
will be inserted just 
within the border of the 

hymen. One other wire suture is then passed by entering the 
needle at the edge of the skin upon the perineal face of the wound. 
The fingers are now withdrawn from the rectum and the sphincter 
thoroughly dilated. 

The levator and sphincter ani muscles have opposing actions. 
To approximate the torn levator fibres and leave the sphincter 
undilated will cause very painful spasmodic contractions in both. 
If the sphincter is paralyzed by forcible dilatation not only will 
the pain after the operation be slight, but gases and fasces will 
readily pass. The operator now sterilizes his hands anew. An 
assistant grasps the upper angle of the wound with a tenaculum 
and lifts it up while the operator ties the upper sutures of ab- 
sorbable material. After all the absorbable sutures have been 
tied each wire suture is then twisted from above downward with 
14 




Fig. 85. — The Apex of the Rectocele is held 
up to show the Angle at which the Vagi- 
nal SUTUKES ARE PASSED (SCHEMATIC). 



210 



GYNECOLOGY 




just enough force to secure nice approximation. It may be found 
necessary to apply approximation sutures of fine tendon between 
the wires. Upon the perinaeum all approximation is by means 
of tendon. The wires are left long and drawn out of the vulval 

orifice. A narrow strip 
of iodoform gauze is in- 
troduced upon each side 
of the sutures within 
the vagina to keep the 
anterior vaginal wall 
away from the line of 
suture. This is re- 
moved in two days and 
afterward the vagina ir- 
rigated daily with ster- 
ile saturated solution of 
boric acid by a careful 
nurse. The wire su- 
tures are removed in 
ten days by clipping 
their loops. It is my 
practice to keep the pa- 
tient on liquid food for 
two days after the oper- 
ation and to evacuate 
the bowels by saline ca- 
thartics once every second clay. Silver wire is used for the tension 
sutures for many reasons. In the first place, they remain sterile 
under all circumstances, the loops made with them remain as loops, 
and do not change their shape under every movement of the mus- 
cles through which the sutures pass, and they can be fastened by 
twisting to the nicest degree of tension and unfastened by un- 
twisting them. This is the method of operating upon incom- 
plete lacerations of the perinaeum, which the author invariably 
employs. Upon consulting the article upon laceration of the 
perinaeum it will be found that this method of operating obeys the 
requirements of all herniotomies; it reduces the protruded viscus, 
the rectum, and approximates the muscular and fascial fibres upon 
whose separation the hernia depends, the levator ani. Stress is 
laid upon the necessity for securely grasping these fibres beneath 



Wall of the Vagina reached by the Denu- 
dation and Highest Sutures. 



PERINEORRHAPHY 



211 



the lateral angles, and upon the angular line in which the sutures 
should be passed, for only in this manner can the muscle and 
fascia be drawn down from the " white line " to which they have 
retracted after being torn (see Fig. 36). Another method of clos- 
ing the torn perinaeum is that devised by Thomas Addis Emmet. 
Although in cases of torn perineum I always employ the method 
first described, there may be found certain cases of long standing 
in which the muscle and fascia have retracted so far as to render 
approximation impos- 
sible. There are also 
other women in whom 
the vaginal outlet is 
merely stretched, 
either by repeated 
child-births, lack of 
muscular tone, or 
masturbation with the 
closed hand. In such 
the Emmet method of 
operating effectively 
narrows the vaginal 
orifice. 

Emmet's. Opera- 
tion. — Tenacula are 
hooked into the points 
where the hymen 
merges into the sides 
of the vulva and are 
then brought together. 
If it is seen that they 
close the vaginal ori- 
fice sufficiently, bits 
of tissue are snipped 
away from beneath 
the tenacula. The 
crest of the rectocele 
is now pulled down by a tenaculum and a point snipped from 
its middle. From this central point and the lateral marks first 
made, incisions through the vaginal skin are passed up on each side 
so as to meet at a point a little over an inch up on each lateral 




t. 87. — The First Step in Emmet's Operation for 
Ruptured Perineum; Denudation of "the An- 
gles." 



212 



GYNECOLOGY 



angle (Fig. 88). The line of demarcation will now resemble 
somewhat a spread-out M. The sutures high np in each angle 
arc preferably of fine tendon, but whenever much tension comes 
upon them they should be of No. 27 silver wire. A description 

of the manner in which 
they are passed is hardly 
necessary when the draw- 
ings are consulted. It 
will be seen, however, 
that this operation also 
seeks the drawing down 
of the levator fibres from 
the " white line " of the 
pelvis. Denudation is 
best made with toothed 
forceps and scissors, and 
before the sutures are 
tied the sphincter should 
be dilated. 

After a perineorrha- 
phy has been properly 
performed it should ac- 
complish certain things. 
The vaginal outlet will 
have been narrowed to 
between -J to 1 inch in 
diameter. The narrow- 
ing of the orifice is not 
seen to extend for at least 
The anus has been ad- 




Fig. 88. 



--Method of passing the 
Emmet's Operation. 



Sutures in 



merely in its skin covering, but is 
f of an inch up the vaginal canal. 



vanced forward, being drawn away from the coccyx, and will 
often appear less tightly contracted than before the operation. 
But the most marked change is in the direction of the vaginal 
canal. In laceration of the perinseum the examining finger 
in entering the vagina will pass upward in the direction of the 
sacral promontory owing to the dilatation and backward displace- 
ment of the vaginal orifice, so that the intra-abdominal pressure 
will bear somewhat in the axis of the vagina. A successful per- 
ineorrhaphy should correct this by lifting the vaginal outlet so 
that the vaginal axis is much below the plane of the pelvic brim. 



PERINEORRHAPHY 



213 










The intra-abdominal pressure will then tend to force the an- 
terior vaginal wall against the posterior and keep the vagina 
closed. 

Complete Rupture of the Perinceum (see Fig. 37). — In addition 
to the break in the pelvic floor, the operator has to correct the injury 
to the lower orifice of the bowel. The operation has, therefore, two 
distinct stages : the closure of the ruptured gut and the reuniting 
of the perineal muscles. The field of operation should be cleansed 
somewhat differently from the usual method, for whatever antisep- 
tics are employed can readily enter the rectum, and that structure 
is particularly sensitive to the influence of antiseptics. Therefore, 
it is wise to content oneself with cleansing the parts by soap and 
water and bichloride-of-mercury solution (1 to 10,000), avoiding 
lysol, creolin, carbolic acid, and other like chemicals. If any anti- 
septic solution enters the rectum it should be carefully sponged out, 
otherwise it may be ab- 
sorbed and cause poison- 
ing. Inasmuch as the 
operation upon the bowel 
is of prime importance, 
and the organ must be 
kept inactive after being 
sutured, it is well to 
thoroughly empty it by 
castor oil three nights be- 
fore the operation, and 
subsequently keep the 
patient upon liquid diet. 
The morning of the oper- 
ation the rectum and co- 
lon should be thoroughly 
flushed in the knee-chest 
posture by enemata of sa- 
line solution. 

The Operation (see 
Fig. 90).— The patient 
is in the lithotomy posi- 
tion. The operator first 

kneads the sphincter ani muscle to stretch it and render it elastic. 
Upon closing the vulva with the fingers, it will be found that 



Fig. 89. — Emmet's Operation completed. 



214 



GYNECOLOGY 



what appears as a slightly curved line between the sphincter 
ends becomes a rent in the recto-vaginal sseptum as the mus- 
cular ends are approximated. The denudation of the perinseum 




Fig. 90. — The Bather Complicated Method of suturing in Complete Laceration 

of the Perineum. 

1 and £, the coaptation sutures through the skin only ; A, I?, the sutures which unite the 

sphincter ani. Above these is seen the running suture which unites the rectal wall. 

and vagina is made exactly as in an ordinary perinseorrha- 
phy (Figs. 83, 84) ; but as the tear in the recto-vaginal septum 
is reached, the operator exercises care in denuding the rectal mu- 
cosa, not to trim off more tissue than will produce a raw surface 



PERINEORRHAPHY 215 

lest disagreeable bleeding be produced. The denudation about the 
anal orifice should begin over the dimple which shows the seat 
of the retracted fibres of the sphincter, and from this point be 
carried around the edge of the thin scar tissue stretching in front 
of the anus, to again dip down to expose the other end of the 
sphincter. It is important that all scar tissue over the sphincter 
ends be removed so as to expose the muscular fibres. The oper- 
ator will know he has secured this result when he can pick up 
and draw out the muscular bundles by means of a tenaculum. 
A tenaculum is now inserted into the middle of the thin tissue 
anterior to the anus while the sphincter ends are approximated 
with other tenacula. In this way the operator will be able to 
fully appreciate the extent of laceration in the posterior vaginal 
wall and the degree of tension when the sphincter ends are united. 
The denudation of the posterior vaginal wall and vulva may be 
carried out either by the method of Emmet (described on page 
207) or, as I prefer to do it, by the operation pictured in Fig. 90. 
While an assistant holds the centre of the recto-vaginal tear up- 
ward a running suture of fine tendon is passed so as to unite 
the rectal mucosa only. Care is to be taken that this suture also 
brings together the lower muco-cutaneous border of the sphincter 
ends. This converts the complete into an incomplete tear with 
rupture of the sphincter. The vagino-perineal sutures are now 
applied as in an ordinary perineorrhaphy, but with more diffi- 
culty because not assisted by the fingers in the rectum. The 
vaginal sutures are tied before those which close the sphincter 
are passed. These latter are inserted in such a manner as to 
secure a close approximation between the sphincter ends and 
leave no dead space between the sphincter and vaginal septum. 
To do otherwise is to invite the formation of either a recto-vaginal 
or recto-perineal fistula at least. All the deeper sutures should 
be of No. 27 silver wire, as the field of operation is inevitably 
infected and requires a suture which is stiff and which will remain 
sterile under all circumstances. The chief cause of failure to 
secure union is the application of too much tension in twisting 
the wires. The tissues should be brought together with just suffi- 
cient force to secure complete juxtaposition and to control paren- 
chymatous bleeding. Spouting arterioles should be ligated by the 
finest tendon and not controlled by suture. It is unwise to em- 
ploy buried catgut to approximate the torn ends of the sphincter, 



216 GYNECOLOGY 

for the risk of infection is thereby increased. Of all the methods 
of direct approximation by means of separate and buried sutures, 
Kelly's is by far the preferable. However, the difficulties in secur- 
ing union by the simpler procedure described are largely of the 
operator s own making. It is upon the skilful application of the 
silver-wire sutures that success depends, and if this material were 
employed with greater frequency and more knowledge of its prop- 
erties the necessity for departing from old, tried, and proven 
methods would not arise, and many of the newer operations, how- 
ever ingenious, would not have seen publication. The application 
of the methods of Emmet and similar procedures in these cases 
left nothing to be desired. The failure of those who followed him 
was due to abandoning silver wire as a suture material and sub- 
stituting the animal fibres for tension sutures. The advocates 
of silver wire as a suture material had only experience upon which 
to base their arguments for it. They were subjected to no in- 
considerable amount of ridicule by those surgeons who see nothing 
good in pure empiricism until experiment proved that under 
all circumstances silver wire remains sterile, and by its oxidiza- 
tion maintains about itself a sterilized field. These properties 
show why the older surgeons so generally succeeded with this 
material. The loudest pleaders for silver wire are now those 
who formerly decried it, and they carry their enthusiasm even 
to the point of burying the wire in hernias, a practice which 
sometimes I follow. The author has digressed somewhat to ex- 
press his enthusiasm for silver wire, for he at one time aban- 
doned it under the weight of opinion offered against it, to again 
return to its use. Throughout the operation the wound should 
be irrigated with sterile saline solution, and whenever the oper- 
ator's hands touch the anal margin they should be cleansed, but 
no antiseptics should be allowed to come in contact with the raw 
surfaces. The deep sutures should be about f of an inch apart, 
and close approximation may be secured by sutures of tendon. 
The sutures approximating the sphincter ends are closer together. 
It is advisable to pass two such sutures through the muscle and a 
third above and external to it to relieve somewhat the strain upon 
these two as well as insure against leaving any dead space between 
the united sphincter and the levator ani fibres. 

After the operation is completed, a rubber or glass tube of 
about \ of an inch calibre should be wrapped with a few folds of 



PERINEORRHAPHY 217 

iodoform gauze and inserted into the rectum to a point above 
the apex of the tear, to provide for the escape of gases, which by 
distending the rectum might burrow beneath the suture line. It 
should be worn for a week, or until the first stool is had. If it 
be found that retraction and atrophy in the sphincter has reached 
so pronounced a degree that the ends of the muscle cannot be 
brought together without undue tension, the muscle may be split 
posteriorly just in front of the coccyx by a subcutaneous thrust of 
the tenotomy knife. This will not require subsequent suture, for 
the gap in the muscle becomes filled in with scar tissue and the 
circle is thereby completed. 

The after-treatment of these cases is of utmost importance. 
They should be kept on a rigid liquid diet for a week. With our 
improved dietetics and the great number of prepared foods in 
the market, the patient can be sufficiently nourished without the 
ingestion of solid food. The upper end of the tube in the rectum 
should not be allowed to press upon the line of union in the rectal 
mucosa, but should extend above it. Wearing a tube in this way 
will maintain a relaxed condition of the sphincter, a desirable 
feature when the bowels move. I exclude milk and all its prepara- 
tions from the dietary because of the hard, caseous masses left 
after its partial digestion. Chicken broth, with rice water or 
toast water, squeezed beef juice, Valentine's extract, liquid pepto- 
noids, etc., given alternately every four hours will sufficiently nour- 
ish the patient. The patient may even have orange-juice and 
apple-sauce. 

On the sixth night the patient is given 6 drachms of castor 
oil, and some competent person should preside over the morn- 
ing's defecation so that in cage hard faecal masses come down 
they may be washed away with frequent saline enemata em- 
ployed placer-mining style, or even broken up with a dull 
curette. 

The sutures are removed on the tenth day, and daily soft 
stools thereafter secured by cascara sagrada. 

The principle governing the after-treatment is perfect rest of 
the parts until union has taken place. 



218 



GYNECOLOGY 



ANTERIOR COLPORRHAPHY 

The operation is indicated whenever a cystocele is present 
of such a size as will not be kept up by a colpoperinaeorrha- 
phy, or when a cystocele exists independent of tear in the 
perinasum. It is particularly demanded in old women, in whom 
the residual urine in the vesical pouch produces cystitis, ureter- 
itis, and pyelitis. I prefer the oval denudation. The operator 
marks a spot on the front wall of the vagina just anterior to the 
protrusion and another just posterior to the cystocele. Then, 





Fig. 91. — The Oval Denudation for 

Cystocele. 



Fig. 92. — Stoltz's Plrse-string Opera- 
tion for Urethrocele. 



upon each side of the anterior vaginal wall, midway between these, 
he picks up the vaginal skin with tenacula and brings them to- 
gether in the middle line. In this way he will determine the de- 
gree of tension. When he finds two lateral points which will 
come together with just the proper tension he marks the spots. 
A curved male sound flattened on the convex side is introduced 
into the bladder, and upon this all cutting is done. The 4 points 
on the anterior vaginal wall are now united by curved lines drawn 
with a scalpel. This surface is then denuded with short curved 



COLPOEEHAPHY 219 

scissors and mouse-tooth forceps. After the entire area has been 
denuded the sutures of Xo. 27 silver wire are passed as illustrated. 
In the after-treatment overdistention of the bladder is to be 
avoided. The wires are removed on the tenth day. It is well 
to give the patient a douche of sterile boric solution each day, 
merely for the purpose of prevention of contamination of the line 
of union. 

Stoltz's Operation. — This is indicated in small cystoceles and 
in urethrocele. The denudation is made in a circle, and as all 
points must be brought to a common centre the requisite degree 
of tension antero-posteriorly as well as bilaterally must be de- 
termined. The suture is entered to one side of the median line, 
appears upon the raw surface, crosses the median line, skips \ 
of an inch, and is passed out upon the undenudated surface, and in 
this way is made to circle, Tike a purse-string, the entire denuda- 
tion. When this has been accomplished the operator draws the 
string taut while an assistant pushes up the centre of the denuda- 
tion witli a sound. The suture is then tied. This suture may be of 
either silk or chromic tendon. If silk is used it must be removed 
in ten days. 

The operation may be done under cocaine anaesthesia, the fluid 
being injected into the vesico-vaginal tissues. Detention in bed is 
unnecessary, the patient merely keeping her room for a week. 



CHAPTER XI 

THE OPERATIONS FOR RETRO-DEVIATIONS OF THE 

UTERUS 

As has before been said, all operations which seek to maintain 
the uterns in a normal position must take advantage of, rather 
than oppose, the intra-abdominal pressure. And to do this the 
operator must determine whether he will select one of the opera- 
tions which will hold the body of the uterus forward or one 
which will fix the cervix high and backward, leaving the intra- 
abdominal pressure to force the corpus uteri forward. It may 
be stated as an axiom that the selected operation should not be 
applied until all pathological conditions in the uterus and its 
adnexa have been corrected. Also, in fixing the uterus in an 
anterior position, care must be exercised not to overdo the re- 
placement so as to make the ligaments of the uterus tense. The 
uterus, for instance, should not be lifted up so high that the 
round and broad ligaments are tense, for they will constantly 
be attempting to pull the organ away from its new attachments. 
The operator must also give due consideration to the function of 
the uterus and not so operate as to render childbearing impos- 
sible. Lastly, he must not disturb the regional anatomy to a de- 
gree sufficient to embarrass adjacent organs. As an example, if 
the uterus be fastened to the abdominal parietes the bladder can 
never be thoroughly emptied. 

Whatever operation is selected should be accompanied or fol- 
lowed by repair of all lacerations of the soft parts. 

We will first take the operations which fasten the body of the 
uterus forward. 

Matthew Manns Operation (Fig. 93). — This is an intra- 
abdominal shortening of the round ligaments. It may be applied 
whenever the abdomen is opened in the median line for adnexal 
disease and the uterus is found retroposed and fixed. The ad- 
220 



KETKO-DEVIATIONS OF THE UTEKUS 



221 



hesions are thoroughly severed and the uterus rendered movable. 
The outer third of one round ligament is then seized by forceps 
and drawn inward so as to be folded upon itself. Another forceps 
grasps the middle third of the ligament and draws it outward, 
making a second loop. A needle threaded with chromic tendon 




Fig. 93. — Matthew Mann's Operation of Intra-abdominal Shortening of the 
Bound Ligahe>ts. 



or silk is made to penetrate both limbs of the looped ligament 
near its angle, and is again passed through the uterine cornu, 
where the round ligament emerges. This suture is then tied. 
A second suture is made to fasten the second loop to the ligament 
as it emerges from the inguinal canal. 

The ligament on the opposite side is similarly treated. 

The operation does not interfere with pregnancy nor make 
labour difficult. It is preferable to all other operations upon the 
round ligaments. 

Ventral Fixation (Fig. 94). — Hysterorrhaphy or hysteropexy. 
The operation is done as a step in a laparotomy for diseased ad- 
nexa where the uterus is found retroposed. It is also performed 
as part of the combination of operations applied for the cure of 
prolapse of the uterus. It is objectionable because it pulls the 
body of the uterus out of the pelvis into the abdomen. With the 
uterus, the bladder is displaced upward; and as the points of 
origin of the round ligaments are raised higher than normal, 
they as well as the broad ligaments pull down against the point 
of fixation of the uterus. As a result, the uterus is either stretched 



222 



GYNAECOLOGY 



out or the new point of fixation stretches. Fortunately the latter 
usually occurs. Another disagreeable result of the operation is 
that it straightens out the utero-sacral ligaments, causing them 
to come together and constrict the rectum. The operation is very 
easy. After all sutures for closing the abdominal wound have 
been passed, two are inserted which penetrate the fascial edges 
of the wound and pass through the fundus of the uterus just back 
of the median line. These fixation sutures are about J of an inch 

apart, and are preferably of 
chromic tendon. When they 
are tied they pull the fundus 
of the uterus upward and ap- 
ply its posterior surface to 
the abdominal peritonaeum, 
where it becomes fixed by 
plastic effusion. A needle 
without cutting edges should 
be used, and the sutures 
should pass deeply into the 
uterine musculature. Fortu- 
nately for the patients sub- 
jected to this operation, the 
uterus does not long remain 
fixed, but merely suspended 
by either a thin sheet of ad- 
Ventral Fixation of the Uterus, hesions or by bands running 

from the abdominal perito- 
naeum to the posterior aspect of the fundus. The operation has 
been found to have little effect upon pregnancy, but undoubtedly 
conduces to faulty presentations of the foetus and to dystocia. 

In certain cases in which the uterus had sunk low in the 
pelvis, and the broad ligaments and vagina had lost their elasticity 
so that it was impossible for me to lift the body of the uterus up 
to the abdominal wall, I have performed the operation which 
is described as liysterocystorrliapliy, or attachment of the uterus 
to the bladder. It has always succeeded perfectly. The point 
where the bladder is attached to the pubis is picked up, and upon 
drawing it tense is found to be firmly fastened to the pubic bone. 
Through this a stout chromic-tendon suture is passed, taking a 
firm grasp of the bladder wall as well as of the peritonaeum. This 




RETRO-DEYIATIOXS OF THE UTERUS 223 

suture is then made to pass through the anterior face of the uterus 
at a point opposite the origin of the round ligaments. Three 
other sutures are passed at ^-ineh intervals through the peri- 
tonaeum of the bladder and anterior face of the uterus. The 
surfaces of the bladder and uterus which will be in apposition 
are then lightly scraped with the scalpel. Upon tying the sutures, 
the one at the pubis first, the bladder and uterus will be united, 
and the uterus will be in exaggerated anteversion. The patient 
wears a self-retaining catheter for a few days after the operation, 
to keep the bladder empty so that the field of operation may be 
kept undisturbed. I have not performed the operation upon a 
woman in whom pregnancy was possible, and would not advise 
it in young women. Objection has been made to the uterus lying 
upon the bladder. This is its normal position before puberty, 
and no inconvenience is caused by it. The operation is far more 
effective than any intra-abdominal plastic operation which can be 
applied to cases of complete prolapse in old women. 

Surgeons have exhibited much ingenuity in devising operations 
for maintaining the uterus in a forward position. Most of these 
have been applied to the fixation of the round ligaments to some 
point of the uterus or into the abdominal wound, but none of 
them seems to be superior to the three procedures I have de- 
scribed. 

The intra-abdominal operations for retro-displacements are, 
with rare exceptions, indicated only when the abdomen has been 
opened for other purposes. They are never to be performed for 
movable retroversion until all other appropriate procedures have 
failed. And they should always be accompanied by curettage and 
such plastic operations upon the cervix and perinaeum as may be 
demanded. It is not wise to merely correct a displacement and 
leave uncured those conditions upon which its occurrence depends. 
To do so is but to invite a recurrence of the false position. 

Alexander's Operation. — This operation is performed for mov- 
able, uncomplicated retroversion. The uterus should not be un- 
duly large or heavy. It and its adnexa should be free from in- 
flammatory changes. The uterus is first replaced and retroflexion 
corrected. Unless plastic operations upon the uterus or pelvic 
floor are to be done at the same sitting, a pessary or dressings must 
be used to hold the uterus up while the ligaments are being short- 
ened. The author does not indorse Alexander's operation, inas- 



224 



GYNECOLOGY 



much as lie never fails to cure by other simpler methods the cases 
for which it is advised. The operation has two disagreeable 
sequelae : hydrocele of the ligament and inguinal hernia. I have 
collected 54 cases of hernia resulting from the operation. Curet- 
tage and properly performed plastic work will cure uncomplicated 
retroposition whenever Alexander's operation can, and without its 
accidents. Pregnancy is not influenced by it. 

The patient is prepared as for a laparotomy, the hair follicles 
about the pubes being carefully painted by tincture of iodine. 
Upon each side an incision an inch long is made from the spine 
of the pubis parallel with Poupart's ligament. The first cut pro- 
ceeds through the skin and fat. The superficial fascia is then in- 
cised and the operator comes down upon the tendon of the internal 

oblique. He now feels for the 
external ring and so adjusts the 





Fig. 95. — Alexander's Operation. 



Fig. 96. — Alexander's Operation. 



i, aponeurosis of the external oblique muscle ; The internal oblique muscle is held up- 

#, the same; 3, internal oblique muscle; ward to expose the round ligament. 

4, the round ligament near its insertion 5, the pubic spine, 
into the pubic fat. 



retractors that he exposes it. It is usually necessary to sever a 
few covering fibres of fascia which lie over the ring, when the 
ligament and some fat come into view. The ligament is recog- 
nised by being round and pinkish. It is either seized by toothed 
forceps or lifted by a blunt hook. All nerve fibres are to be 



KETKO-DEVIATIONS OF THE UTEKUS 



225 



pushed aside by blunt dissection and the ligament grasped between 
the finger and thumb. The ligament is pulled out 3 or 4 inches, 
or until a resistance is felt. If its peritoneal sheath appears, it 
is stripped back with the fingers. A suture of chromic tendon 
or silver wire is passed through the skin and fascia of one pillar, 
then through the ligament, to emerge through the fascia and skin 
of the other side. The ligament is cut off and another suture is 





Fig. 97. — Alexander's Operation. 

Tenacula are holding the fascial edges apart. 
Shows the method of passing the suture. 
i, aponeurosis of external oblique mus- 
cle ; 2, the same ; 3, internal oblique mus- 
cle ; .£, round ligament ; 6, Poupart's liga- 
ment. 



Fig. 98. — Alexander's Operation. 

Shows the effect of drawing the suture 
taut. 



inserted to close the wound, 
which may be made to pass 
through the stump of the 
ligament. The wounds are dressed by iodoform gauze and 
cotton. If silver wire is used it is removed in two weeks. 
Chromic-tendon suture does not have to be removed. This 
is the simplest method of operating, but the ligament is not 
often so easily secured. The following is the usual procedure 
adopted : The incision extends for 2 inches from the pubic spine 
parallel to Poupart's ligament, and the aponeurosis of the exter- 
nal oblique is exposed (Fig. 95). A grooved director is in- 
15 



226 



GYNECOLOGY 




serted beneath this, and it is split nearly to the internal ring and 

along the fibres of the external oblique. The internal oblique 

is seen crossing the upper part of the canal, and beneath it the 

ligament may be seen (Fig. 96). It can. always be found by 

retracting the internal oblique and hooking up the contents of 

the canal. The ileo-inguinal nerve lies along the outer side of the 

ligament. This latter is drawn out of the canal, and its investing 

_ peritonaeum is .stripped back as it ap- 

-- ; '\ pears. When the ligament has been 

W • I pulled out about 3 inches, or until 

tension is felt, the first suture is 
passed. But one deep suture is used. 
It pierces the aponeurosis of the ex- 
ternal oblique at the inner upper 
angle of the wound, then the internal 
oblique and transversalis muscles, 
the margins of the internal ring, the 
round ligament, and Poupart's liga- 
ment. A third inch lower down the 
next loop pierces the internal oblique, 
transversalis, round ligament, and 
Poupart's ligament (Fig. 97). The 
last loop takes in the outer pillar of 
the external ring and comes out upon 
the aponeurosis of the external ob- 
lique. The same suture pierces the 
internal pillar of the external ring, 
the round ligament, and external 
pillar. The round ligament is now 
cut off close to the last loop of the 
suture. The suture is then carried upward, uniting the fibres 
of the external oblique aponeurosis, and is tied to the other 
end of the suture (Fig. 99). This deep suture is of medium- 
sized chromic tendon. The skin is closed by a subcuticular suture 
of silver wire. The several steps of the operation should proceed 
upon both sides as nearly simultaneously as possible to avoid un- 
due tension upon one ligament. If a plastic operation upon the 
cervix is necessary it should be done before the ligaments are 
shortened, and if the perinaeum needs repair this is to be clone 
after shortening the ligaments. 



Fig. 99.- 



-Alexander's Opera- 
tion. 



Showing the manner in which the 
suture unites the fibres of the 
external oblique aponeurosis. 1 
and 2, external oblique aponeu- 
rosis ; 4-, stump of the round lig- 
ament. 



RETRO-DEVIATIONS OF THE UTERUS 



227 



The author s operation (Fig. 100) is employed to correct adher- 
ent retropositions. The patient is prepared locally and generally, 
as for vaginal hysterectomy. The uterus is curetted, and any nec- 
essary plastic operation upon the cervix is now performed. The 
posterior cul-de-sac is then opened and a careful digital examina- 
tion is made. Should pus be found, all further attempts at replace- 
ment are abandoned, and the case is treated as one of pelvic sup- 
puration. But if the pelvic contents are seen to admit of conserva- 




Fig. 100. — The Author's Operation for Adherent Eetropositions. 

Sagittal mesial section of the field of operation to show the corrected position of the 

uterus and retaining dressings. 



tism, the adhesions are severed and appropriate treatment applied 
to the ovaries and tubes. The pelvis is then wiped dry. A gauze 
pad (Fig. 101) is introduced into the pelvis and the table lowered 
into Trendelenburg's position. Into each angle of the incision one 
chromic-tendon suture is passed. The pad is now removed and the 
two sutures tied. This will close the vaginal incision except for about 
-| an inch in the centre. Into this opening a wick of gauze is passed 
so as to reach just above the cut edges. The uterus is then packed, 




228 GYNAECOLOGY 

if necessary. Over this enough strips are placed to fill the incision 
in the vagina. This gauze plug, together with the uterus, is next 
replaced. It is easily done, as the patient is lying head down and 
the intestines have left the pelvis. Holding the uterus in position 
by means of the trowel or any depressor pushing against the cervix, 

pieces of gauze are inserted to the 
sides of the cervix and in front of 
it until the vagina is filled to the 
margin of the levator ani muscle. 
The operator now takes a stout 
roll of gauze as thick as his thumb 
101.— Gauze Pad secured by and as long as the width of the 
Stout Linen Cord. distended vagina, usually 2 inches. 

Used for the purpose of catching dis- Thig j caU pessary. One 

charges and retaining the viscera J ° x ^ 

during pelvic operations. end of this is introduced in front 

of one side of the cervix, just be- 
hind the levator ani fibres, and the other end is pushed into a 
similar position on the other side. This plug will lie transversely 
across the vagina and in front of the cervix. It will prevent de- 
scent of the cervix even in face of the most violent vomiting. 
The uterine packing should be so arranged that it can be removed 
without disturbing this anchoring plug. 

A self-retaining catheter is introduced and the bladder is emp- 
tied every two hours for two days. The bladder is then irrigated 
with boric-acid solution and the catheter withdrawn. The uterine 
packing is now removed without disturbing the vaginal. In seven 
to ten days the patient is placed in Sims's position. All dressings 
are removed and replaced exactly as were the first. The operation 
will fail unless the supporting plug is properly inserted. This is 
as important as the suture in other operations. The second dress- 
ing is applied a week later, is painless, and after it the patient 
sits up. I keep up these dressings as long as there is any raw 
surface at the vaginal vault. The supporting tamponade I use 
for six weeks. I then fit a pessary which is so shaped as to keep 
the cervix backward by pushing against its anterior lip, and with- 
out bearing upon the posterior scar. This instrument should be 
worn for several months. If perinaeorrhaphy is indicated, it 
should not be performed until the scar posterior to the uterus is 
thoroughly organized into fibrous tissue. If at any time the dress- 
ings are so applied that they allow of descent of the uterus, they 



RETKO-DEVIATIONS OF THE UTERUS 229 

have been improperly inserted. The cervix must be kept high and 
backward until the cul-de-sac opening closes and the post-cervical 
scar has contracted. The operation leaves the corpus uteri per- 
fectly free. Pregnancy resulting after the operation is uninter- 
rupted and labour is normal. The wick of gauze which is inserted 
between the edges of the incision lies over the rectum and between 
the utero-sacral ligaments. Around this gauze lymph forms which 
attaches the cervix to the rectum and utero-sacral ligaments. The 
cervix becomes anchored in a high and backward position. Intra- 
abdominal pressure acting upon the uterus forces the uterine body 
forward. 

The operation in my hands takes the place of all other opera- 
tions for fixed retropositions. It has a wider range of application 
than any other procedure, and can be used in all cases not present- 
ing pus. When the retroposition is accompanied by occluded tubes, 
by hydrosalpinx, by cystic ovaries, etc., this is the preferable opera- 
tion. But when pus is present in either ovary or tube, removal 
of this and replacement of the uterus can only be accomplished by 
laparotomy. 



CHAPTEE XII 

PREPARATION OF PATIENT FOR CAPITAL OPERATIONS 

It is important that the kidneys be led to the elimination 
of not only a normal quantity of urine, but that they be prepared 
to withstand the tax which will be placed upon them by the opera- 
tion. If they be structurally diseased, it is of prime importance 
to know the degree of the changes. It is through the kidneys 
that the products of disturbed metabolism are eliminated, and not 
only the smoothness of convalescence but also the result of the 
operation will depend much upon the activity of the kidneys. 
The first effect of an operation is to cause the excessive formation 
of urea, and in certain cases of toxalbumins. The more dilute 
the urine the greater the facility with which these are eliminated. 
Furthermore, the physical comfort of the patient is much im- 
proved if the kidneys be active after the operation. It is my 
practice to administer large quantities of water for several days 
before I operate, for the purpose of increasing the amount of 
urine excreted and to reduce the specific gravity of the urine to 
about 1.010, or even less. At the same time the ingestion of water 
before operation lessens the post-operative thirst. There are cer- 
tain hours after a laparotomy during which it is undesirable to 
give fluids, owing to the irritability of the stomach, and during 
these the system loses fluid through the activity of the skin and 
kidneys. Therefore a surplusage of fluid in the system provides 
against this loss. This surcharging of the body with water is 
accomplished by the patient drinking from two to four pints of 
water each day for two days before the operation, and by the 
administration of enemata of normal salt solution in quart quan- 
tities every twelve hours, and with the patient in the knee-chest 
posture. Of course these statements apply only to cases in which 
an elective operation is to be performed. There may also be con- 
230 



PREPARATION FOR CAPITAL OPERATIONS 231 

tra-indications in certain diseases, such, for instance, as where a 
tubo-rectal fistula is suspected, to giving the eneniata. 

The bowel function is not to be neglected. Women are habitu- 
ally costive. It is well to give a calomel purge five days before 
operation, the bowels being kept regular afterward by aromatic 
cascara sagrada. Intra-abdominal operations, and all operations 
which necessitate general narcosis, conduce to intestinal torpor. 
If an operation be performed while the bowels are loaded with 
faeces, putrefaction of the faecal matter results, the patient suffers 
from " retention toxicosis/' the abdomen becomes tympanitic, the 
stomach deranged, and not only is the post-operative discomfort 
much augmented, but the danger to the patient is actually in- 
creased, as well as the success of the operation jeopardized. These 
remarks apply with particular force when it is intended to per- 
form surgical operations upon the intestines themselves. And if 
the patient be tympanitic in spite of the free evacuation of the 
bowels, it is well to overcome this by withdrawing all the gas- 
producing vegetables and by the administration of salol for three 
days preceding the operation. 

Too little attention is paid to the correction of digestive dis- 
turbances before operation and a careful estimation of all the 
physical elements which influence convalescence. I have but al- 
luded to the two most important factors. The administration of 
strychnine and other heart tonics are indicated, and if the patient 
is used to alcoholic stimulants, I give wine at two meals. There 
is no objection to a substantial diet for four days preceding an 
operation, all preserved foods and shell-fish being excluded. The 
day before the operation the diet is liquid, consisting chiefly of the 
expressed juice of broiled steak and chicken broth. 

Abdominal Section. — The pubis and vulva are shaved two days 
before the operation. A poultice of strong soap-suds is applied 
over the abdomen from the breast-line to the pubic bone and left 
on twelve hours. It is then removed, the soap washed off, and 
a thick dressing of gauze wet in mercuric bichloride solution (1 
to 5,000) is put on in its stead. It is covered by rubber tissue 
and held in place by adhesive straps. This is renewed once in 
twelve hours. "When the patient is placed on the operating-table 
the abdomen is scrubbed by lysol solution (1 per cent) and then 
by bichloride (1 to 5,000). The skin is then dried and the line of 
incision as well as the umbilicus is painted by tincture of iodine. 



232 



GYNAECOLOGY 



This powerful diffusible antiseptic penetrates every hair follicle. 
Examination of epithelial scales after this method of cleansing 
the abdomen shows that the skin is sterile. 

The abdominal cavity may be entered in the median line, in 
the linea semilunaris, or by a crescentic incision above the pubis. 

Median Abdominal Section (Fig. 102). — If the incision ex- 
tends from a point 1^ inch above the pubic cartilage to a little 




Fig. 102. — Transverse Section of the Frozen Body at the Level of the 
Umbilicus. (Braune.) 

a, umbilicus ; w and 6, rectus muscle ; u and c, great omentum ; v and d, ureter ; e, trans- 
versalis muscle: t and/, internal oblique muscle; g and s, external oblique muscle; 
h, ascending colon; p and i, quadratus lumborum muscle; j and g, psoas muscle; fc, 
inferior vena cava ; Z, cartilages of third and fourth lumbar vertebrae ; m, spinous 
process of fourth lumbar vertebra ; «, process of third lumbar vertebra ; o, descend- 
ing aorta; r, descending colon; «, transverse colon. «, at the linea alba; c, at the 
semilunar line. 

below the umbilicus, the following structures are severed : the 
skin, the subcutaneous fat, the deep fascia, the linea alba, the 
subperitoneal fat, and the peritonaeum. If the incision passes 
to one side of the median line it proceeds through the following 
anatomical layers: the skin, the fat, the anterior lamella of the 
rectus fascia, the rectus muscle, the posterior lamella of the rec- 
tus fascia, the subperitoneal fat, and the peritonaeum. In nullip- 
arae the linea alba is narrow and is easily missed in the incision, 



ABDOMINAL SECTION 233 

while in multiparae it is stretched and is hroader. If the inci- 
sion extends down to the pubis, as I always make it. it passes 
through the juxtaposed pyramidalis muscles beneath the linea alba. 
In women who have had children and when the bladder is drawn 
up by tumours, this part of the incision does not pass through 
the peritonaeum, but enters the retropubic or prevesical space. 
It is therefore at this point that the incision in suprapubic cys- 
totomy is made. If the median incision is to pass above the 
umbilicus, this depression is excised, otherwise union will be jeop- 
ardized and an asymmetrical scar produced. In excising the 
umbilicus the adjacent portions of the linea alba will be removed 
and the two recti muscles exposed with their two lamellae of 
fascia. Above the umbilicus the incision will pass through skin, 
fat, fascia, subperitoneal fat, and peritonaeum. A few veins of 
minor importance are severed in the incision. At a point about 
1J inch above the pubis a branch of the superficial epigastric 
artery may be cut just beneath the fat. Beneath the fascia very 
minute branches of the deep epigastric arteries are severed as 
they cross the median line to anastomose with those on the oppo- 
site side. 

The operation proceeds in the following manner : the operator 
stands at the patient's right. With the separated index finger and 
thumb of the left hand the skin is drawn up and tightened. The 
belly of the scalpel is drawn downward with force enough to pene- 
trate the skin. The left thumb and index finger separate the edges 
of the wound and the scalpel is drawn through the fat down to the 
fascia. All bleeding veins are grasped by artery forceps, and any 
spouting artery is ligated. An assistant holds apart the fat edges 
and the operator incises the fascia very carefully. If he has 
struck the linea alba he will now come down upon subperitoneal 
fat. If he sees muscular tissue he knows he has passed through 
the outer lamella of the rectus fascia and has exposed the rectus. 
It is therefore advisable to make the fascial incision short at 
first until the exact situation is determined, for if the rectus is 
exposed, the operator makes another incision nearer the median 
line so as to strike the linea alba, unless he wishes to pass through 
the rectus. Upon reaching the subperitoneal fat it will usually 
be forced up between the lips of the wound. It is covered by a 
very thin layer of fascia, which is incised so that the operator can 
introduce two fingers, with which he tears the fat apart along 



234 GYNAECOLOGY 

the whole length of the incision. Beneath this is the peritonaeum. 
Assistants hold apart the severed tissues, using for this purpose 
Jackson's retractors. The operator picks up a fold of peritonaeum 
with toothed forceps and an assistant does likewise opposite him. 
The resultant ridge of peritonaeum is carefully nicked. The oper- 
ator introduces one or two fingers along which he incises the 
peritonaeum, using blunt-pointed scissors for this purpose. When 
the peritonaeum is first exposed careful inspection will show two 
longitudinal bands of dense fibrous tissue running upon each side 
of the median line. These are the remains of the umbilical ar- 
teries. Very rarely they contain a minute arteriole, and therefore 
the peritonaeum should be incised between them. Upon entering 
the abdominal cavity, the omentum commonly, the small gut 
often, protrudes through the incision. If either happens the es- 
caped organ should at once be returned and a gauze pad intro- 
duced to retain it. At first the incision is made only long enough 
to permit of the introduction of two examining fingers. If the 
operation is to continue farther, the incision is to be carried down 
to the pubis. By separating the pyramidales and recti at this 
point the maximum separation of the edges of the incision is 
secured. Furthermore, the nearer the incision to the pubic bone 
the less the danger of subsequent hernia. The operation com- 
pleted, the incision is to be closed. I attach much importance 
to the prompt closure of the peritoneal edges by a running suture 
of very fine tendon or gut. Within a short time (less than two 
hours) the union is complete, and adhesion of the intestine to the 
peritoneal incision is less likely. Interrupted sutures, about \ an 
inch apart, are passed through the fascia. These are of chromic 
tendons, and in thickness -^ of an inch. The skin and fat are 
approximated by a subcuticular suture of No. 27 silver wire or 
by 1 strand of boiled silkworm gut. To do this the needle is 
entered above and to one side of the upper limit of the incision 
and passed through the skin (Fig. 103). It comes out on the 
cut face of the fat, is made to take a firm hold of the opposite 
derma beneath the epidermis, is crossed to the other side and 
made to catch the derma there, and in this way proceeding down 
the incision the operator finally plunges the needle through the 
fat and skin below and to one side of the lower limit of the in- 
cision. The needle should emerge upon the side opposite 
from the point of its introduction. As the wire is drawn 



ABDOMINAL SECTION 



235 



taut a very pretty approximation of the skin edges is secured. 
The ends of the suture are clamped by split shot, or rolled over 
a piece of gauze. The edge of the incision is covered by sterile 
gauze, which is secured by zinc-oxide plaster strips. Instead of 
applying the sterile gauze along the incision, I very often cover 
the cut with many layers of silver foil. This in oxidizing acts as 
a protection against infection. The foil is kept in place by cotton 
and plaster. This is the preferable method of closing the incision. 
But if a long incision has been made, thus weakening for a dis- 
tance the abdominal wall, or if the operation has been prolonged, 
or if for any reason the operator fears vomiting, struggling, or 
coughing after the operation, a more secure procedure may be ap- 
plied. The interrupted fas- 
cial sutures are passed and 
tied at inch intervals. A 
carrying thread is intro- 
duced close to the skin edge 
at the upper limit of the 
wound, and is made to pass 
through skin, fat, and fascia. 
It should enter the fascia 
midway between the tendon 
sutures. Upon the opposite 
side the needle passes up- 
ward through fascia, fat, and 
skin. This procedure is car- 
ried out throughout the length of the wound. The carrying threads 
are used to pull through interrupted sutures of No. 27 silver wire. 
In this method of suturing the silver wire is made to supplement 
the absorbable suture, and a secure and nice approximation of all 
the anatomical layers is obtained. The silver wires are twisted 
many times. Silver wire should not be used as a subcuticular 
suture if the incision be over 3 inches in length, because it clings 
to the tissues and its removal is difficult. Thus, in all incisions 
over 3 inches, if the subcuticular suture is employed it should be of 
silkworm gut. 

The ends of the wires are left long and folded over a strip of 
mild iodoform gauze. Another strip of iodoform gauze is then 
laid alongside the wound opposite the first. Over the whole sterile 
gauze is placed, to be retained by plaster. The wires are removed 




Fig. 103. — The application of the Subcu- 
ticular Suture with Silver "Wire. 
x, point of last emergence of the needle. 



236 GYNECOLOGY 

in three weeks by cutting their loops on one side. In obese women, 
when it is hopeless to attempt primary union between the thick 
fat walls, it is advisable to close the essential layers in the follow- 
ing manner: carrying threads are drawn as interrupted sutures 
through fascia, muscle, and peritonaeum. Then these are made to 
draw through silver wire of size No. 26. These wire sutures are 
twisted and the ends left long. No attempt is made to close the 
skin and fat, but the wound is filled by mild iodoform gauze 
upon each side of the wires. The dressings are renewed once 
every four days, and the silver-wire sutures are removed in two 
weeks. A wound 5 inches in depth will close in seven weeks. 
Granulations do not appear if the wound be kept aseptic, for the 
cavity closes by the production of histological plasma cells, which 
spin a tissue similar to that from which they spring — namely, 
connective tissue. It is impossible to lay down hard-and-fast 
rules for the application of the various methods of suturing, but, 
as a general rule, if the fat wall be about \ an inch in thickness, 
the preferable method is interrupted absorbable sutures through 
fascia, muscle, and peritonaeum, and interrupted silver-wire su- 
tures through skin, fat, and fascia, these latter, as they pass through 
the fascia, being midway between the absorbable sutures; or, when 
the abdominal fat is above 1 inch and not over 2J inches in thick- 
ness, the fascia, muscle, and peritonaeum are approximated by 
stout interrupted sutures of absorbable material, and the fat and 
skin by a continuous subcuticular suture of silver wire. When the 
belly fat is over 3 inches in thickness it is better to leave it open; 
or, if it is closed, it should be by the second method, and between 
the silver-wire sutures filaments of iodoform gauze should be 
introduced down to the fascia to drain away the oil which always 
oozes from such fat surfaces. 

The Lateral Incision. — This is the incision of Langenbeck 
through the semilunar line (Fig. 102). 

It is employed chiefly in nephro-ureterectomy, but in certain 
cases of ascending infection upon the right side it affords the 
operator an opportunity to inspect and treat the adnexa, the 
vermiform appendix, the kidney, and the gall-bladder. It can 
be made to extend from the ribs to Poupart's ligament, but is 
usually made from a point \ an inch above Poupart's ligament to 
3 inches higher up. The incision should pass just external to the 
rectus muscle, and in its course severs the skin, fat, external 



ABDOMINAL SECTION 237 

oblique fascia, internal oblique fascia, transversalis fascia, sub- 
peritoneal fat, and peritonaeum. 

As each of these layers is severed it is held apart by an 
assistant, who uses for this purpose toothed retractors until the 
transversalis fascia appears, after which only blunt retractors are 
employed lest the teeth of the sharper instruments wound the intes- 
tines. In closing such an incision there should be 3 distinct 
layers of sutures. The deepest, of absorbable material, are inter- 
rupted, and approximate the peritonaeum and transversalis fascia; 
the second, of absorbable material, are interrupted, and bring to- 
gether the fascias of the internal and external obliques, while the 
skin is united by a subcuticular suture of silver wire. In no 
instance should all the fascial planes be united by one set of 
sutures, for the direction of effort of the various abdominal mus- 
cles attached to these are somewhat antagonistic. 

The vessels cut in the operation are the external branches of 
the deep epigastric artery. If the incision is carried down too 
far and close to the external ring of the inguinal canal there is 
danger of wounding the deep circumflex iliac artery. 

The Curved Transverse Incision. — This is employed in exten- 
sive extraperitoneal operations upon the bladder, and for the pur- 
pose of performing transperitoneal operations upon the pelvic 
viscera. A curved incision is made from one external inguinal 
ring to the other, the cut extending through skin and fat only. 
The concavity of the incision is upward, and its centre just misses 
the pubic symphysis. The fat is held apart and the rectus fascia 
is divided transversely. As the muscles appear, the fascia is dis- 
sected upward from the muscles and the fascial flap is turned 
upward. The recti and pyramidales are then torn apart by blunt 
dissection in a vertical direction, but the subperitoneal fat and 
peritonaeum are cut through. Care must be taken not to wound 
the bladder. This incision will open the prevesical space, as well 
as the peritoneal cavity, the latter for a short distance. During the 
operation the bladder should be kept empty by means of an open, 
self-retaining catheter. In closing the incision the peritonaeum 
should be united by a continuous suture of absorbable material, 
and the pyramidales and recti by interrupted sutures. The fascia 
of the recti is united by interrupted sutures of absorbable mate- 
rial and the fat and skin closed by a subcuticular suture. The 
resulting scar becomes largely covered by pubic hair. As the 



238 



GYNECOLOGY 




Fig. 104. — Brush fob scrubbing the Vagina. 
It is imported and should have no back. If it has 
it will come apart when boiled. It is sterilized 
by boiling ten minutes in plain water, after 
which it soaks one hour in 2 per cent lysol. 



**£ 



incision is of limited length, large growths cannot be removed 
through it. The above procedure is that of Hartmann, of Paris, 
and is preferable to all of 
its kinds. 

Vaginal Section. — The 
pubis and vulva should be 
shaved two days before the 
operation. Unless there is 
a profuse flow of pus from 
the uterus, or the opera- 
tion is done in an emergency, I pack the vagina full of sterile 
gauze ringing wet in bichloride-of -mercury solution (1 to 5,000) 
for two days, renewing it each day. This will cause exfoliation of 

the superficial layers of 
vaginal epithelium and 
sterilize the field of oper- 
ation. If the purulent 
leucorrhcea is so profuse 
as to dam up in case the 
vagina be packed, the 
vagina may be irrigated 
every twelve hours with 
large quantities of bi- 
chloride solution (1 to 
5,000). At the time of 
operating, the buttocks, 
vulva, and vagina are 
scrubbed first with a J- 
per-cent solution of lysol 
and then with bichloride 
solution (1 to 5,000). 

The pelvic cavity may 
be entered by an incision 
posterior to the uterus 
or by one anterior to it 
(Fig. 105). 

The Posterior Incision. — The bar to a thorough inspection of 
the pelvic cavity through the vagina is the uterus, and a great em- 
barrassment experienced in the procedure is prolapse of the intes- 
tines into the vagina. If a posture can be secured which will 




Fig. 105. — The Various Incisions in the Vagina 
employed to enter the pelvis for purposes 
of removing growths, evacuating fluids, ex- 
PLORING the Pelvic Contents, removing the 
Uterus, and doing Operations upon the Ad- 
nexa. 

c, s, d, the line of incision employed in posterior 
incision ; s, <, Henrotin's incision to enlarge the 
latter ; h, c and d, r, Segond's incision to enlarge 
c, s, d ; a, g, 6, this with c, s, d, are the incisions 
employed in vaginal hysterectomy; a, gr, b with 
/, g are the incisions used in anterior incision. 



VAGINAL SECTION 



239 



prevent the latter, and an incision adopted which will remove the 
uterus out of the way without injuring it, vaginal exploration 
of the pelvis will supersede the abdominal. The author believes 
that his procedure secures both the desirable factors essential 
to success. 

It must be remembered that the distance from the vulva to the 
cul-de-sac is even less than from the abdomen to the cul-de-sac. 




Fig. 106. — As the Cervix is shoved up by the Forceps tvhich holds it, a Cres- 
centic Fold is seen over the Point of Keflectiox of the Peritonaeum from 
the Cervix. 

Therefore, the cavity explored from below is not as deep as when 
sought from above. The ability to see the pelvic structures 
through the vagina is then dependent upon the space secured. 
The space is not so much limited by the vulva as by the condition 
of the tissues about the cervix. If the vaginal incision posterior 



240 



GYN/ECOLOGY 



2 inch from side to side, the elastic tissue will 



to the cervix is 1| 
yield under the pressure of the retractors to make the opening at 
least 1| inch wide by over 2 inches antero-posteriorly. But in the 
rare cases of pronounced sclerosis the elasticity of the vaginal vault 
may be found so limited that sufficient space cannot be secured 




Fig. 107. — The Incision Posterior to the Cervix ; the latter held by a Bullet 

Forceps. 

through which to make an adequate visual inspection. The opera- 
tor will then have to depend almost wholly upon his sense of touch. 
Operation. — The patient is placed upon the table in the lith- 
otomy posture, with the ischial tuberosities over the edge of the 
table. The perineum is retracted by a short Jackson specu- 
lum and the uterus is pulled down. The uterus is curetted and 
swabbed out, but not packed with gauze. The vagina is wiped 
dry. Upon shoving the cervix upward a fold will be seen to 



VAGINAL SECTION 241 

form just opposite the cervico-vaginal junction. The vagina 
is incised here, scissors being used for the purpose. The scis- 
sors cut through vaginal mucous membrane only. The incision 
is commonly 1 inch long and extends to the lateral borders 
of the cervix (Fig. 105). There now remains but one tissue to 
sever — the peritonaeum. The uterus is held firmly down and the 
operator pushes his index finger into the cul-de-sac. In doing this 
he is careful to keep the point of his finger accurately in the mid- 
dle line and pressed up against the posterior uterine wall. If after 
pushing the tissues up to the level of the internal os the finger has 
not entered the peritoneal cavity, the point of the finger is directed 
backward and pushed into the cavity. If the peritonaeum is very 
thick it is caught with toothed forceps and incised with scissors. 
Commonly serum escapes when the cavity is entered. 

In making the incision one small vessel is severed — the azygos 
artery of the vagina. 

It requires forcipressure very rarely, being an insignificant 
vessel. Having entered the pelvic cavity, a gauze pad, to which 
a string is attached, is introduced into the pelvis. While the oper- 
ator washes his hands, an assistant lowers the table into the Tren- 
delenburg position (Fig. 4). At once all unattached viscera leave 
the pelvis. The operator now inserts his two index fingers into 
the rent, and upon separating his hands the incision is spread later- 
ally. This tear takes place in the line of the incision. A careful 
digital examination is now made of the pelvic contents. The finger 
glides up along the smooth posterior uterine wall as high as the 
fundus and is then swept laterally over one cornu and tube. The 
ovary and tube upon one side are carefully palpated. If tender 
adhesions are met with they are torn with the finger. Unless pus 
is suspected, the effort is made to free the ovary and tube from 
adventitious union. The operator remembers that his finger has 
entered below the plane of the bases of the broad ligaments, and 
that his manipulations are behind the broad ligaments upon their 
posterior surfaces. 

At once this will indicate to him the method of separating 
adherent adnexa. In doing this the finger is moved between the 
surfaces of union from the side of the uterus upward and out- 
ward, a sort of lifting motion being made. All the time the 
adnexa are being manipulated the uterus is firmly held down with 
the bullet forceps. The pelvis is now wiped free from blood. If 
16 



242 GYNECOLOGY 

firmly adherent adnexa or cystic accumulations are met with, it 
is better not to complete their separation before inspecting them. 
Inspection of the pelvis is next made. A medium Pean retractor 
is introduced, and the perinaeum, vagina, and posterior edge of 
the incision are held down by it. The cervix is loosed from the 
grasp of the bullet forceps, and a Pean-Pryor trowel is inserted 
behind the uterus. The soiled pad is now removed, and several 
clean ones are inserted. The uterus is pushed up behind the 
symphysis and out of the pelvic cavity by the trowel. This is the 
very essence of the procedure, for by it the obstructing uterus is 
lifted out of the way. By dexterous manipulation of the trowel 
the adnexa of first one side and then the other are exposed to 
view. When seen they may be grasped with ovary forceps and 
brought clown into the vagina, where they may as readily be 
operated upon as is the cervix in plastic work. 

If the thickening about the cervix is so dense as to render the 
tissues inelastic, an increase in space may be secured by making a 
cut through the centre of the posterior vaginal wall down to a 
point opposite the bottom of the cul-de-sac (Pig. 105, s, t). 

Having done such work upon the uterus, pelvic peritonaeum, 
or adnexa uteri as is indicated, the pelvis is wiped dry and the 
gauze pads removed. Another small pad is introduced and the 
sutures for closing the incision passed. The peritonaeum at 
one angle is caught up with bullet forceps and drawn out. A 
stout curved needle is then passed through the four layers and 
held by an assistant (Fig. 108). The angle of the other side is 
similarly treated, and other sutures passed between the two at 
the angles at -J-inch distances sufficient to secure a good approxi- 
mation. The gauze pad is then removed and the sutures tied. 
A light vaginal pack of iodoform gauze is placed over the in- 
cision; or the incision may be left either wholly open or partially 
closed for gauze drains. I prefer small chromic kangaroo tendons 
as suture material. 

Anterior Incision. — The bladder is emptied and the perinaeum 
retracted by means of Jackson's speculum. The uterus is pulled 
down after curettage and a circular incision is made anterior to 
the cervix and through the vaginal mucosa only (Fig. 105). 
From the centre of this another incision passes down the anterior 
vaginal wall as far as desired, even to the urethral mound. The 
lateral flaps are then separated and the bladder, by blunt dissection 



VAGINAL SECTION 



243 



with the finger, is freed from the uterus. As the vesico-uterine 
fold of peritonaeum is felt the bladder is held up by the narrow 
trowel. When the peritonaeum is exposed it is caught by toothed 
forceps and cut transversely. 

If it is desired to draw down the body of the uterus, a blunt 
needle threaded with heavy silk is passed deeply into the anterior 
face of the uterus and the thread used for traction purposes. If 
it is wished, the round ligaments may be drawn into the wound and 
each folded upon itself, thus shortening them. The sutures doing 
this are then passd one upon each side through the middle of the 
vaginal flap and tied. 
The traction string is 
cut and withdrawn, 
and the peritonaeum 
closed by suture. At 
this stage small ves- 
sels which have been 
severed in the cervico- 
vesical attachment are 
sought and secured. 
The wound is now 
closed. Chromic- 
tendon sutures are 
employed through- 
out. The vagina is 
packed with iodoform 
gauze. The patient 
keeps in bed for two 
weeks. 




Fig. 1( 



owing Method of closing the Poste- 
rior Vaginal Incision". 



Through such an 
incision as this the 
various conservative operations may be performed upon the adnexa, 
fibroids in the anterior wall of the uterus removed, or small ovarian 
cystomata removed. The operation has the disadvantage of proceed- 
ing anterior to the broad ligaments, whereas the adnexa lie behind 
these, and the greater additional disadvantage in that it furnishes no 
drainage at the lowest pouch of the peritonaeum. It has but a limit- 
ed application. The trauma inflicted by it is as great as that accom- 
panying laparotomy, and the author does not employ the operation 
except to remove fibromata from the anterior wall of the uterus. 



CHAPTER XIII 
MYOMECTOMY 

Abdominal. — Indications. — Enucleation of a nterine myo-fibro- 
ma through an abdominal incision is indicated when the patient is 
young or very desirous of bearing a child ; when the tnmonr is pe- 
dunculate, or sessile even, provided the trauma inflicted upon the 
uterus will not impair its function or subject the patient to a risk 
much greater than would follow a more radical operation ; particu- 
larly when there is reason to believe but one tumour is present ; and 
never unless a precise explanation has been given the patient re- 
garding the value of this operation and of hysterectomy, and the 
possibility of a repetition of operative procedure owing to the 
formation of new growths. The mortality attending myomectomy 
is largely governed by the amount of trauma inflicted upon the 
uterus. Therefore this operation, when applied to sessile and 
multiple fibromata, carries with it a risk greater than that at- 
tending the removal of a very large pedunculate fibroid. Fur- 
thermore, the nearer the growth to be removed is to the large 
arterial trunks the greater the risk. 

The operation is contra-indicated in fibro-cystic tumours; 
should rarely be done when pus is present about the uterus; never 
when the pedicle of the tumour is necrotic from torsion; never 
in retro-peritoneal tumours or in intraligamentous, or in tumours 
lying hidden between the bladder and cervix. It is a safe rule 
never to apply this operation to sessile tumours in which the 
greatest diameter of the growth is attached to the uterus, for the 
trauma and difficulty in controlling the haemorrhage are so great 
as to jeopardize the vitality of the organ. 

Operation. — The abdomen is opened in the median line. Upon 
viewing the uterus and tumour, the four cardinal anatomical points 
of the organ are to be noted (the Fallopian tubes and round liga- 
244 



MYOMECTOMY 245 

ments), for upon their mutual relations will depend the relation 
of the tumour to the uterine cavity and the arterial supply. If 
the tumour is pedunculate a circular incision is made through 
the peritonaeum a little above the insertion of the tumour. The 
attachment of the tumour to the uterus is then cut away 
by a cone-shaped incision. After removal of the growth the 
larger vessels are secured by very fine tendon ligatures and the 
muscular parts of the pedicle are approximated by interrupted 
sutures. 

The ends of these are cut short, and a running suture closes 
the peritonaeum over the wound in the uterus. In enucleating the 
pedicle of the growth the uterine cavity must not be entered, and 
in closing the wound all bleeding must be stopped by the sutures 
in such a manner as not to produce sloughing by strangulation. 
The particular danger from the operation lies either in the ina- 
bility to control the bleeding after the pedicle is severed or in the 
too snug approximation of the tissues by multiple sutures in the 
attempt to stop all oozing. The incision of the pedicle should be 
made parallel with the course of the vessels so as to sever as few 
as possible, and this will usually be bilaterally. The abdomen is 
to be closed without drainage. 

If the tumour is sessile a linear incision is made through its 
capsule down to the white fibres of the tumour. The edges of the 
cut are then held apart and the tumour seized by forceps or fast- 
ened by a corkscrew. It is then dug out of its bed by blunt- 
pointed closed scissors or by a periosteum elevator, all bleeding 
vessels are secured, and the cavity is closed by tiers of tendon 
sutures. 

Vaginal. — Indications. — In all retro-peritoneal, intraligamen- 
tary, and retrovesical fibro-myomata which do not demand hyster- 
ectomy and are not too large to pass the vaginal outlet. It is 
also applicable to intra-uterine tumours under certain conditions. 
The operation is contra-indicated in all fibro-cystic growths. The 
operation is contra-indicated in all cases where the tumour springs 
from the uterine body at a point higher than the vesico-uterine 
fold. It will be seen that the indications for this operation contra- 
indicate abdominal myomectomy, and vice versa. 

Operation. — The uterus is curetted. By means of an appro- 
priate incision the tumour is exposed. In intraligamentary 
growths by a cut along the base of the broad ligament, in retro- 



246 GYNAECOLOGY 

peritoneal fibroids by incising the vagina posterior to the cervix 
and peeling the peritonaeum off the tumour, and in vesico-uterine 
tumours by dissecting the bladder from the uterus. So soon as 
the tumour is exposed it is fixed by means of the corkscrew. This 
will furnish a firm grip upon the growth, and the operator then 
proceeds to dissect the tumour from its investing capsule. This 
is preferably accomplished by using a closed pair of blunt-pointed 
curved scissors as an enucleator. After the tumour is enucleated 
the incision is closed except a small space in the centre, which is 
left open for an iodoform-gauze drain. There are no particular 
dangers in the operation. In intraligamentous tumours the uter- 
ine artery must be carefully felt for and avoided. 

Removal of Intra-uterine Growths. — The cervix has been pre- 
viously dilated by means of sterile laminaria tents, or it is in- 
strumentally dilated at the time of operating. The latter is the 
preferable method. The operation is indicated whenever the 
tumour can be removed through a cervical canal which has been 
artificially enlarged. By the exercise of patience very many cases 
now subjected to hysterectomy can be successfully treated in this 
manner. 

The cervix is dilated as fully as possible by the branched dila- 
tors or until the examining finger can be introduced. In these 
cases the cervical canal is generally patulous and readily dilated. 
If sufficient dilatation cannot be secured, the cervix may be split 
bilaterally or even in a stellate manner by means of a blunt bis- 
toury. Guided by the finger, a corkscrew is forced into the tu- 
mour. The mucous capsule of the growth is next incised and 
peeled off the tumour. As soon as the glistening fibres of the 
tumour are seen, the latter is grasped close to the corkscrew with 
heavy toothed forceps and rotated, while by means of blunt dis- 
section the growth is dug out of its bed. Or the capsule is first 
split and then the tumour is fastened by the corkscrew and dis- 
sected from its bed below and laterally as far as the operator 
can reach, and grasped by Sims's fibroid hook, the corkscrew 
removed, and the growth pulled clown; the capsule is then 
peeled up and another hold secured by another hook. In this 
manner, alternately rolling down the tumour and peeling up the 
capsule, it is entirely freed from its bed. Tumours may in this 
way be loosened even when too large to be pulled through the 
cervix. They are then seized by the forceps and split in two or 



MYOMECTOMY 247 

more pieces by a blunt bistoury and removed in fragments. After 
the tumour is removed, a digital examination of the uterine cavity 
is made to detect other growths, and the loose flaps of capsule 
are trimmed away by scissors. The uterus is thoroughly curetted 
and packed full of 20-per-cent iodoform gauze. This dressing 
is changed in three days. Any incisions in the cervix are not 
closed now, but later. As the sole danger in the operation is 

FROM SEPSIS, A WIDE-OPEN CERVIX AND THE FREEST DRAINAGE ARE 
NECESSARY. 

ABDOMINAL HYSTERECTOMY FOR FIBROID 
DISEASE OF THE UTERUS 

Indications. — Hysterectomy is the operation of choice in all 
cases of general fibroid degeneration of the uterus which need 
operative treatment, while the operations just described are those 
of election under certain circumstances. The abdominal removal 
of the fibro-myomatous uterus is particularly indicated in growths 
which have reached the umbilicus, and especially in the softer 
tumours, such as the cystic and angiomatous. Upon discovering 
a fibroma the propriety of operating at all will depend upon the 
symptoms the growth produces or which it is known it will pro- 
duce if let alone. After operative procedure is decided upon the 
question of myomectomy or hysterectomy comes up; and if the 
latter, whether by the abdomen or vagina. I have expressed my 
preference for hysterectomy over myomectomy as a general rule. 
If these growths occurred singly myomectomy would be the opera- 
tion of choice, but when I have carefully examined the fibroid uteri 
I have removed, I have seldom failed to discover multiple, though 
perhaps very small, nodules in addition to the greater tumour 
which necessitated this operation. Women with fibroid uteri are 
notoriously sterile in a percentage far greater than in anteflexion 
even. It is difficult to see how myomectomy can relieve this, and in 
fact it rarely does. So this form of conservatism is not substanti- 
ated by the experience in its application. The argument for hyster- 
ectomy based upon the supposition that fibroids become malignant 
has no foundation in analysis of these growths. Fibroid uteri are 
more frequently associated with cancer than are uteri not fibroid. 
But we must not forget that cancer is most prevalent after the 
age of thirty-five, and it is at this time also that the nidus of a 



248 GYNECOLOGY 

fibro-myoma usually becomes active. If the operator believes as 
I do in the multiplicity of fibromata, then he must expect after 
a myomectomy to have the latent and undiscovered fibroid foci 
at some future day produce other growths which will demand 
removal. If this belief is laid before the patient she will usually 
elect the radical operation or the palliative treatment. The danger 
of myomectomy is in direct proportion to the amount of injury 
inflicted upon the uterus during its performance, as, for instance, 
in multiple fibroids. And if the fibroids are multiple myomectomy 
is useless, for all the tumours can never be removed in such cases, 
overlooked foci being always left. As much as one must admire 
the operative skill of him who has perfected this operation of myo- 
mectomy for multiple fibroids, the operation must be always con- 
sidered as incomplete and as fraught with more danger than 
accompanies the ablation of the tumour-bearing organ. However, 
one may remove all growths which are pedunculate and put the 
patient upon mammary or thyreoid extract to produce absorption 
of the intramural growths in the hope that she may bear children, 
or in obedience to the very pardonable sentiment which women 
have against removal of their special organs. A greater experi- 
ence with improved forms of thyreoid extract may establish this 
as the rule to follow. Hysterectomy should, if possible, be avoided 
in women under thirty-five years of age, for in them disagreeable 
psychic symptoms often supervene and genital atrophy is sure to 
result. It cannot be too often repeated, nor with too great em- 
phasis, THAT FIBROID UTERI ARE NOT TO BE REMOVED UNLESS PRO- 
DUCING disagreeable or dangerous symptoms. These are repeat- 
ed and uncontrolled haemorrhages, pressure upon nerves or ureters, 
or bladder or bowels, and rapid growth. Tumours of large size 
should always be removed, as they undermine the general health. 
Fibro-cystic and angeiomatous tumours, those of rapid growth as 
well as those which are multiple, should be treated by hysterec- 
tomy. Fibro-myomata, accompanied by tubo-ovarian disease so 
severe as to necessitate removal of the adnexa, always indicate 
hysterectomy. Likewise infected fibroids and those associated with 
pelvic suppuration always demand hysterectomy. 

The Operation. — The vagina should be prepared and cleansed 
as for a vaginal section, and the abdomen sterilized as for all 
laparotomies. The abdomen is opened in the median line. The 
regional relations of the involved organ are determined. A 



ABDOMINAL HYSTERECTOMY 



249 



careful examination of the ovaries is now made, and unless 

THESE ARE MANIFESTLY DISEASED THEY ARE NOT TO BE REMOVED. 

As a rule, one or both must be sacrificed because of interstitial 
changes, or because so involved in adhesions to the uterus. Ab- 
dominal hysterectonry may be performed in several ways. 

(a) (Fig. 109). The ovarian arteries are ligated at the pelvic 
brim. The bladder is next dissected away from the cervix down to 
the vagina until the uterine arteries can be felt. These are then 
ligated, a curved aneurysm needle passed around them, carrying 
the ligatures. The round ligaments are next ligated a little dis- 
tance away from the uterus. By means of an incision which passes 
down one side the ovarian vessels are severed, then the round 




Fig. 109. — Schematic Drawing showing the Position of the Ligatures ox the 
Ovarian and Uterine Arteries, also the Ligatures at the Cornua Uteri to 
control the Ovarian Arteries where they anastomose with the Uterines. 
See Fig. 119 for the arterial dissection. 



ligament and broad ligament, the uterine arteries are cut along- 
side the cervix, and the vagina is entered. The uterus is then 
tilted over to the other side. The incision now passes up through 
the vagina, broad ligament, round ligament, and ovarian vessels. 
Smaller vessels, such as branches from the vaginal arteries, may 
require ligatures. By means of this operation the symmetrically 
enlarged uterus is readily and speedily removed. 

(b) If there be an intraligamentous nodule upon one side, 
and usually when the uterus is large, the procedure is different. 
Here both ovarian vessels are ligated and both round ligaments. 
The bladder is then separated from the uterus by an incision 



250 



GYNECOLOGY 



passing across the uterus at the cervico-vesical fold, and the blad- 
der is peeled down until the vaginal cervix can be felt through the 




Fig. 110. — The Abdomen has beetst opened and the Tumour and Adnexa delivered. 
Z, the umbilicus; #, gauze pad to hold back the intestines; 3, the left ovary and tube; Jf., 

the right ovary and tube ; 5, the fibroid uterus. The operator's hands are uncovered. 

His assistants wear rubber gloves. 

anterior wall of the vagina. The tissues are now carefully cut 
on the free side: first, the ovarian vessels, then the round liga- 




Fig. 111. — The Uterus is drawn to the Left, and the Surgeon is passing the 
Pedicle Needle threaded with Tendon Ligature beneath the Right Ovarian 
Vessels outside the Right Ovary. 

i, the umbilicus ; £, gauze pad holding back the intestines ; ^, opposite the top of the 
right broad ligament which contains the ovarian vessels ; 5, the fibroid uterus. 



ABDOMINAL HYSTERECTOMY 



251 



ment, then the broad ligament, until the uterine artery is felt. 
After severing the top of the broad ligament the uterine artery 
is best exposed by separating the folds of the broad ligament and 
shoving them down by blunt dissection with the fingers. The 
uterine artery is now ligated or clamped and the cervix cut away 
from the vagina upon this side and anteriorly. The uterus is 
now forcibly pulled out towards that side upon which the intra- 
ligamentary nodule is situated, and the cervix is grasped with 




Fig. 112. — The Top of the Eight Broad Ligament has been cut and the Tumour 

IS DRAWX FAR OVER TO THE LEFT. BeTWEEX THE FOLDS OF THE ElGHT BROAD 

Ligament the Curled Uterine. Artery is seex. Bexeath this the Pedicle 

Needle is passixg. 

i, above the stump of the ovarian artery ; 2, the sigmoid colon ; 3, placed upon the cervix 
uteri; 4, the left adnexa; 5, the right Fallopian tube; 6, pedicle needle. 



powerful traction forceps and lifted up also. This renders the 
vagina tense, and by means of scissors the cervix is entirely cut 
away from the vagina. The base of the broad ligament is opened 
up and the uterine artery exposed beneath the intraligamentary 
nodule. The artery is ligated and cut close to the cervix. It is 
now an easy matter to peel the fibroid nodule from between the 
layers of the broad ligament. The ovarian vessels and round liga- 



252 GYNECOLOGY 

ment upon this side are cut, and a few snips with the scissors cut 
the loose folds of the broad ligament. The uterus is now re- 
moved. Although the four cardinal vessels have been secured, 
lesser arterial trunks as well as veins may need ligatures before 
all bleeding ceases, particularly in the posterior vaginal wall and 
utero-sacral ligaments. This is the operation which the author 
almost invariably performs. Instead of applying ligatures as the 
operation proceeds, the several vascular stumps may be caught by 




Fig. 113. — The Right Uterine Artery has been tied and the Cervix cut loose 
upon the Right Side so as to enter the Vagina. The Cervix is held high 
up while a Ligature is thrown around the Left Uterine Artery. 

#, on the rectum beneath, the vaginal orifice ; 3, on the cervix ; 4, over the left adnexa ; 5, 
the fibroid uterus ; 6, the ligature around the left uterine artery which is plainly seen. 

clamps which are afterward replaced by ligatures without the em- 
barrassing presence of the tumour. 

(c) If both sides contain intraligamentous nodules the case is 
most difficult. The ovarian vessels are first secured, then the round 
ligaments, and the bladder is dissected from the uterus until the 
vagina can be felt. The anterior face of the uterus is now split 
so that the uterine cavity is entered throughout its length and 
the cervix cut open so that the vagina is entered. By means of 
serrated traction forceps the lips of the incision are held apart. 
Upon one side the uterine cavity is cut up and down through its 




Fig. 114. — The Cervix has been cut away upon the Left Side and the Base of 
the Left Broad Ligament severed. The Mass now hangs by the Top of the 
Left Broad Ligament only, in which is the Left Ovarian Artery. Around 
this a Ligature is thrown. 

i, right adnexa; 2, rectum ; 3, cervix ; 4, left aclnexa ; 5, fibroid uterus ; 6, ligature around 
the left ovarian vessels. 




Fig. 115. — The Uterus and Adnexa have been removed, and the Vagina packed 

with Gauze. 
i, bladder; £, rectum; 3, gauze in vaginal orifice; 4, gauze pad holding back the intestines. 

353 



254 GYNECOLOGY 

musculature towards the corresponding broad ligament so as to ex- 
pose one intraligamentary nodule. A corkscrew is worked into 
this, and it is rapidly dug out of its bed. This half of the uterus 
at once becomes movable. The next step is to ligate its uterine 
artery, complete the hemisection of the uterus, and cut away this 
half of the uterus. Upon the other side the same procedure is 
carried out. The object of removing the intraligamentary nodules 
through the severed uterine walls is to produce symmetry upon 




Fig. 116. — Showing the Relations when a Large Retro-peritoneal Nodule 

exists. 

The same relations are present when a similar noclule springs from the posterior uterine 
wall but above the peritoneal reflection as in this ease, c, c, between these letters 
the uterus and fibroid capsule must be split before the fibroid can be extracted. 

each side of the pelvis successively, thus allowing the ureter, 
often displaced over the broad ligament, to recede to its usual 
situation and thus escape injury. 

(d) If there be a retro-peritoneal nodule the hemisection of 
the uterus is made until the nodule is exposed (Fig. 116). It is 
then removed, and the uterus becomes movable and the pelvic 
anatomy symmetrical. 

(e) If there be a nodule anterior to the uterus, between the 
bladder and uterus, the ovarian vessels and round ligaments are 
first secured, after which the bladder is dissected off the tumour 
(Fig. 117). The anterior face of the uterus is next split so that 
the nodule can be removed. The operation is then completed 
in either the first or second forms described. 



ABDOMINAL HYSTERECTOMY 



255 



Adhesions to the viscera are dealt with as described under 
Ovariotomy. But with fibroid tumours these new attachments 
are most vascular. If a pus ovary or tube is found, it is advisable 
to remove this before proceeding to the hysterectomy lest the pus 
sac rupture and soil the spaces opened into beneath the perito- 
naeum. When an ovarian tumour coexists with a small fibroid 




Fig. 117. — A Nodule springing from the Anterior Uterine Wall. 

Notice the position of the bladder, drawn out of the pelvis above the pubic bones, c, c, 
between these letters the capsule of the fibroid must be split before the fibroid can 
be extracted and the uterus rendered movable. 



uterus the whole may be removed together; but if the fibroid be 
large, its removal is facilitated by first taking away the ovarian 
growth. 

If the myoma is complicated by cancer of the uterus, the re- 
moval of the organ must be of that radical type advised for can- 
cer. Vaginal hysterectomy is not possible because of the large size 
of the organ, and it must be removed as described under Abdom- 
inal Hysterectomy for Cancer of the Uterus. 

After the uterus has been removed the pelvis should be wiped 
dry and each ligature carefully inspected to see if it is holding 
securely. Several strips of iodoform gauze are then introduced 
into the vagina, their ends just projecting above the cut edges 



256 



GYNAECOLOGY 



of the vagina (Fig. 115). Beginning at one stump of a ligated 
ovarian artery, a running suture is tied, and by proceeding down 
the pelvis the peritoneal surfaces are approximated, then across 
the vaginal opening and up the other side, the suture being tied 
at the opposite ovarian ligature (Fig. 116). This will close out 
the field of operation from the general pelvic cavity. The gauze 




Fig. 118. — Schematic Drawing to show the Method of closing the Vagina over 
the Uterine Stumps, and the Method of uniting the Folds of the Broad 

Ligaments. 



drain is introduced because there is always more or less oozing 
of bloody serum after the operation. The rectum is adjusted 
so as to touch the bladder, the omentum drawn down, and the 
abdomen closed. The vaginal drain is removed in a week and 
is renewed. Upon its removal in five days no further dressing 
is needed and the patient is put upon daily douches of boric-acid 
solution. 

It will be observed that removal of the cervix is advised. The 
reason for this is that the operation is generally simpler than it 
would be were the cervix left; removal of the cervix allows of 
perfect drainage, a most desirable thing when infection of the 
fibroid or of the adnexa exists; to save the cervix in complicated 
cases renders the operation more difficult, and if the cervix is left 
it may break down into cancer later, or be the seat of gonor- 
rhoea] infection. If an intraligamentous nodule has been removed. 



ABDOMINAL HYSTERECTOMY 



257 



and in all cases of infected fibroid, fibroid with cancer and fibroid 
with pyosalpinx, the folds of the broad ligaments may be united 
by a few sutures, but it is advisable to leave the vault of the 
vagina open for drainage, the vagina being filled with iodoform 
gauze. In reality, this in a few hours becomes extraperitoneal 
because the bladder and rectum speedily unite over the gauze. 




Fig. 119. I 

a, Fallopian tube; 6, artery to the tube; c, artery to the ovary; d, ovary; e, round liga- 
ment ; /, uterus ; g, uterine artery alongside the uterus ; h, broad ligament ; i, ovarian 
artery; j, ureter; fc, uterine artery as it passes the ureter; /, rectum; m, levator ani 
muscle ; n, branches to the vagina ; o, vagina ; p, inferior vesical artery ; q, bladder ; 
r, ureter ; s, uterine artery ; t, peritonaeum ; u, ovarian artery (Spalteholz). 



The mortality from abdominal hysterectomy for myofibroma 
uteri is not over 2 per cent. But in fibro-cystic tumours the 
mortality is much higher, reaching at least 10 per cent. This is 
due to the coexisting cardiac lesions which so often accompany 
fibro-cystic disease. 




a - 


my* VO 




x , ■ 


e / 


' /A 



Fig. 120. — Arteries of the Female Pelvis. 

a, external iliac artery ; 6, inferior epigastric artery ; c, obturator artery ; d and h, round 
ligament ; e, superior vesical artery ; /, obliterated hypogastric (umbilical) artery ; g, 
inferior vesical artery ; i, uterine artery ; j, ureter ; 1c, bladder ; I, uterus ; m, symphy- 
sis ; n, artery of the clitoris; o, posterior labial artery; p, artery of the clitoris; q, 
levator ani muscle ; r, inferior hemorrhoidal artery ; s, internal pudic artery ; t, 
vagina ; u, inferior vesical arteries ; v, superior vesical arteries ; w, ureter ; x, obliter- 
ated umbilical artery ; y, vaginal artery ; z, superior hemorrhoidal artery ; 1, uterine 
artery ; 2, vaginal artery ; 3, inferior vesical artery ; 4, ovarian artery ; 5, artery to 
the Fallopian tube ; 6, internal iliac artery ; 7, external iliac artery ; 8, rectum ; 9, 
middle sacral artery ; 10, lumbar branch ; 11, common iliac artery ; 12, inferior mes- 
enteric artery ; 13, ureter ; 14, fourth lumbar artery ; 15, aorta ; 16, ureter ; 17, ovarian 
artery ; 18. iliacus muscle. 
258 



VAGIJSTAL HYSTERECTOMY 259 

VAGINAL ABLATION OF THE FIBROID UTERUS 1 

Indications. — The operation is indicated in all cases where 
there is a not too great disproportion between the growth and the 
vaginal outlet. In old women with shrunken and rigid tissues it 
is more difficult than in the younger, whose tissues are elastic. 
It is particular^ indicated in retroperitoneal and intraligamentous 
tumours. As a rule, growths which do not reach above the um- 
bilicus can be removed in this manner. In fibrocystic disease this 
operation is contra-indicated unless the tumour is small, for the 
soft uterus cannot be pulled down, and powerful down-traction is 
a necessary element in the successful performance of the operation. 

Since 189-1 the author has been applying to flbro-myomata 
the vaginal method of operating, and an analysis of his cases shows 
that of all cases of fibroid coming to him 80 per cent were sus- 
ceptible of treatment through the vagina. In the vaginal opera- 
tion conservative treatment of the adnexa is more difficult than 
in the abdominal operation. The vaginal operation is particularly 
indicated in those cases which, when approached through the ab- 
domen, are most difficult — the cases having retroperitoneal and 
other growths about the cervix. 

Operation. — The chief aim of the operator is to so reduce the 
volume of the mass that it is rendered movable and susceptible 
of extraction en masse or after the classical hemisection. In doing 
this care must be exercised not to wound the great arterial anasto- 
mosis which lies upon either side of the uterus. The tissue is 
removed piecemeal by the procedure known as morcellement; and 
as each successive fragment is cut away that above is drawn down 
by stout toothed forceps. In order that these latter may hold in 
the tissues the structure of the uterus and tumours must be of 
fair firmness. It is because of the absence of this element of firm- 
ness that fibro-cystic tumours, unless small, should not be at- 
tacked through the vagina. 

Taking as a typical example of the procedure a uterus which 
is nearly symmetrically enlarged, the first incision is into the 
posterior cul-de-sac. Through this a digital examination of the 
pelvis is made. A gauze pad secured by a stout string is then 

1 This article should be read in conjunction with the one on Vaginal Abla- 
tion in Pus Cases. 

17 



260 



GYNAECOLOGY 



introduced into the pelvis. This posterior incision is then con- 
tinued around the cervix. The cervix is now seized by Pean's 
4-pronged blunt forceps, and the operator begins the separation 
of the bladder from the uterus. This is accomplished by blunt 
dissection with the fingers, the palmar surfaces of which are 
pressed against the cervix; the bladder is literally rubbed up off 
the uterus. When this dissection has proceeded as high as the 

operator can reach, 
that portion of the 
bladder which has 
been freed is held up 
by the narrow trowel. 
The 4-pronged for- 
ceps is then removed 
and each angle of the 
cervix is seized by 
bullet forceps. The 
middle of the ante- 
rior lip of the cervix 
is then split by scis- 
sors as high as the 
attachment of the 
bladder. Each angle 
of this cut is seized 
by the sharp toothed 
traction forceps and 
rolled outward. As 
this is done the ute- 
rus will descend a 
little, and the opera- 
tor can dissect up 
the bladder a little 
farther. The tissue 
of the cervix thus ex- 
posed is incised. Pro- 
ceeding in this way, 
alternately dissecting up the bladder and splitting the exposed 
uterine tissue, the operator enters the peritoneal pouch anterior 
to the uterus. Uusually this section of the anterior uterine wall 
will have proceeded a little above the level of the internal os 




Fig. 121. — Scheme of Incisions into the Uterus in 
performing morcellation of the flbroid organ. 

Extending through the centre of the entire anterior wall 
is the central incision. 1 and #, the sections first re- 
moved from the cervix ; 3 and 4, the sections first re- 
moved from the body of the uterus ; 5 and £, second 
sections from the uterine body ; 7 and 8, large sec- 
tions from the fundus uteri. Following along the 
outer dotted line it will be seen that three-fourths of 
the anterior wall of the uterus can be removed with- 
out injuring large arteries. 



VAGINAL HYSTEEECTOMY 



261 



before the peritonaeum is severed. The operator next pushes 
the bladder away upon each side with his fingers, thus still further 
tearing the peritonaeum bilaterally and completely freeing the 
uterus from its vesical attachments. It will now be seen that the 
body of the uterus is too large to pass the pelvic outlet. First 
from one side of the median incision, then from the other, a 
V-shaped piece of tissue is cut away with the scissors. As each 
piece is removed the stump above is seized by the sharp-toothed 
forceps. After removing a piece from each side of the middle 
line, the uterus can 
be brought still far- 
ther down. This 
downward displace- 
ment will often be 
facilitated by pres- 
sure by the closed fist 
of an assistant ap- 
plied behind the pu- 
bis. More tissue is 
cut away upon each 
side in successive 
stages until the cor- 
nua appear beneath 
the bladder. The or- 
gan is then in shape 
for completion of the 
hemisection, upon 
finishing which the 
hysterectomy forceps 
are applied and the 
halved uterus re- 
moved. If fibroid 
nodules appear as the 
organ is cut, they are 
grasped and dug out 
of their capsules, 

thus reducing the size of the organ by that much. When large 
nodules are exposed they are best held by the corkscrew and so 
reduced in size by fragmentation that they can be extracted. All 
during the operation the uterine canal must be kept in view as 




Fig. 122. — The Effect of the Morcellation is to 

RENDER THE UTERINE WaLLS NOT ONLY SMALLER 

but More Pliable. 

This drawing shows how the cornua can be folded in- 
ward so as to be brought down beneath the bladder. 



262 GYNAECOLOGY 

being the chief landmark for the guidance of the operator as 
he makes his incisions. If the chief nodule is located either 
between the bladder and uterus or beneath the peritonaeum and 
posterior to the cervix, it is first attacked, for unless such a growth 
be removed the uterus will remain immovably fixed. The hemi- 
section can proceed with comparative ease in intraligamentary 
growths, for they usually leave sufficient space between the uterus 
and symphysis for the section. And as the level of the intraliga- 
mentous nodule is reached the corresponding half of the uterus 
is cut into laterally so as to expose the nodule, when it can be re- 
moved. If there be a large pedunculate subperitoneal nodule pres- 
ent it may be necessary to remove the uterus first before securing 
this, but such a procedure is unusual, and if necessary an assistant 
should hold the fibroid by his hand, grasping it above the pubis lest 
it escape into the abdominal cavity. As a rule, it will be found that 
after completely dividing the uterus each half may be held to the 
side so that a corkscrew can be fastened into the pedunculate fibroid 
and its. removal effected. Prolapse of the intestines is prevented 
by operating in the author's position or by the introduction of 
gauze pads secured by strings. But the presence of these is 
always an embarrassment. In making down-traction as the sec- 
tion proceeds, if this be done in the centre of the pelvis the organ 
may appear immovably fixed, whereas if it be rotated from side 
to side as it is drawn down, rarely will a more movable portion 
of it fail to appear of size sufficient to cut away. Even after 
the cornua appear it may be impossible to draw the fundus down 
sufficiently to complete the hemisection, and then it may be neces- 
sary to cut out a wedge from the fundus. The hysterectomy for- 
ceps are applied exactly as in the similar operation for pus in the 
pelvis. Whereas there are four cardinal vessels supplying the 
uterus, in fibroid disease the arterial supply may be atypical. 
The chief variation will be in the existence of a stout branch of 
anastomosis across the front of the cervix from one uterine artery 
to the other. If this is cut in the section of the organ it should 
be ligatured before proceeding further. The dressings are applied 
as described under the operation for pus, and the after-treatment 
is the same. The mortality from this operation is nil. It is 
unfair to compare it with the abdominal operation, for that opera- 
tion has to contend with those huge growths which furnish com- 
plications high in the abdomen. Yet the, vaginal operation sue- 



VAGINAL HYSTEEECTOMY 



263 



eessfully overcomes complications which are most difficult to 
handle through the abdomen — intraligamentous and retro-perito- 
neal outcroppings. The great advantages attending the vaginal 
operation are found in the absence of section of the belly wall and 
manipulation of the small intestines, both of which are necessary 
in the abdominal operation. Therefore, interintestinal adhesions 
and ventral herniae are not sequelae of the vaginal operation. 




Fig. 123. — The Fibroid Uterus, Ovaries, and Fallopian Tubes from a Maid of 

Forty-two Years. 
The mass reached to the umbilicus. Eemoved by morcellation through the vagina. 

The loss of blood during the operation is not serious if the 
section does not wander out too near the " pink tissue " at the 
sides of the uterus in which are the large vessels. 1 The operation 
may be classified as the extraperitoneal treatment of the stump, 
but differing from the old operation of Hegar in which the stump 
was fastened outside the abdominal cavity above the pubis, in that 
with the vaginal operation the stump is divided into 4 parts, and 
all drainage is at the lowest point of the peritoneal pouch and 
through a tube which does not absorb and does not become in- 
fected — the vagina. 



1 If the section of the uterine musculature is accompanied by embarrassing 
bleeding, this may be checked by deep injections of adrenalin (1 to 2,000) forced 
into the uterine tissues upon each side of the median line, as first suggested 
by Dr. Gordon, of Montana. 



CHAPTER XIV 

OVARIOTOMY 

Abdominal Ovariotomy. — This is the removal of an ovarian 
tnmonr through an abdominal incision. If the tumour is small 
it may be removed by any of the abdominal incisions. Tumours 
of a diameter greater than 5 inches are preferably removed by 
the median abdominal incision. Because oe the tendency of 

OVARIAN CYSTOMATA TO CONTAIN SEPTIC ELEMENTS, OR SIMPLE 
BUT MALIGNANT PAPILLOMATA, OR CANCEROUS PAPILLOMATA, THEY 
SHOULD ALWAYS BE REMOVED UNRUPTURED IF THIS BE POSSIBLE. 

The tumour is attached to its corresponding cornu uteri by means 
of a pedicle. This latter is composed of the ovarian ligament 
and upper part of the broad ligament, and the Fallopian tube is 
more or less involved. Upon examining the pedicle it will be seen 
to contain large venous sinuses, and arterial trunks may be seen 
and felt pulsating within it. 

Operation. — Upon opening the abdomen the operator intro- 
duces so much of his hand and arm as will enable him to 
determine the presence and extent of adhesions. If none are 
present he extends his incision so as to enable him to even- 
trate the tumour. This is accomplished by holding the tumour 
up against the incision while the assistants depress the lips of the 
incision. As the tumour mass escapes it is rocked from side to 
side so as to facilitate its extrusion. Upon turning out the tumour 
the exact relations of the pedicle are determined by careful in- 
spection. 

Escape of the intestines is prevented by the introduction of 
a number of gauze pads, and other pads are arranged about the 
pedicle to catch bloody discharges when the pedicle is ligated and 
cut. An assistant should support the tumour so that it will not 
drag on the pedicle. The operator feels for a spot about the 
264 



OVAKIOTOMY 265 

centre of the pedicle in which there are no vessels and perforates 
this with a blunt aneurysm needle. The eye of this is then 
threaded with two heavy tendon ligatures and the needle is made 
to draw these through the pedicle. The needle is now laid aside, 
and the ligatures locked together by one twist. One half of the 
pedicle is next tied,, the operator making the first knot single and 
employing the force steadily and long enough to reduce the elas- 
ticity of the tissues to a minimum, and the second and third 
knots are quickly tied. The other half of the pedicle is similarly 
treated. All strain upon the pedicle is now released and it is 
cut at a point above the ligatures high enough to leave enough 
stump to prevent the ligatures slipping off. The larger and more 
prominent vessels are now seized and separately ligated with very 
fine tendon. The objection to this method of securing the pedicle 
is the formation of a large mass of dead material outside the 
ligature, part of which becomes absorbed and part revitalized. 
By far more preferable is the method of Skene, by which the 
stump is dehydrated and rendered sterile, to become revitalized 
long after the vessels of the stump are obliterated. The larger 
the stump the greater the indication for this method of haemos- 
tasis. The gauze pads are removed, the pelvis wiped dry, and the 
wound closed. 

Certain complications are often met with in dealing with 
ovarian tumours. The adhesions to the abdominal parietes are 
best separated by the hand, which is passed carefully around the 
periphery of the tumour. Adhesions to the intestines are severed 
by scissors, all the dissection being at the expense of the tumour- 
wall; and the small thin layer of capsule left after such a pro- 
cedure is united at its edges by a fine running suture so as to 
leave only its peritoneal covering exposed. Particular care must 
be employed in dealing with adhesions to the visceral mesenteries, 
for to produce there a bleeding which will require ligation of 
vessels would invite gangrene of the gut. 

If the adhesions are so extensive or the tumour so large that 
they cannot be readily reached, it may be necessary to tap the 
tumour if cystic in order to reduce its bulk and permit of a careful 
dissection. To do this the edges of the incision, both beneath and 
above, are protected by gauze pads. The patient is rolled upon 
her side and the sac is grasped by any blunt polypus forceps, like 
Luer's or Hunter's. The tension may be so great that this is 



266 GYNAECOLOGY 

impossible, and the sac must be at once tapped. The fluid is 
best evacuated through a large curved trocar. As the fluid escapes 
its physical characteristics are noted, and as the sac collapses it 
is drawn out of the wound so that its opening is entirely extra- 
peritoneal. After the fluid has ceased to flow lesser lobules may 
be broken into by the hand introduced through the incision in the 
main tumour. Often this procedure produces great haemorrhage 
from the vessels ruptured in the trabecular of the tumour. In 
such an instance the pedicle must at once be grasped by heavy 
hysterectomy forceps and the separation of the adhesions between 
the tumour and viscera proceeded with. Should any fluid escape 
into the abdominal cavity the latter should be washed out by 
sterile saline solution after the tumour is removed and the pedicle 
ligatured. 

If the tumour upon inspection proves to be inlraligamentary 
there is no pedicle. Such a growth arises from the parovarium. 
Here one of two courses may be pursued. If the tumour be large, 
that part of the capsule which shows fewest important anatomical 
structures should be carefully incised. Such a point will com- 
monly be between the Fallopian tube and ovarian ligament. 
Through this incision enucleation of the tumour is attempted. 
Or the tumour may be tapped, and after the pelvic anatomy has 
again become symmetrical a pedicle may be formed of the col- 
lapsed capsule. When the tumour has not risen above the pelvic 
brim it is the author's practice to operate by the vagina, opening 
the posterior cul-de-sac, evacuating the tumour by incision at its 
base, and inserting a gauze drain into the cavity. These tumours 
are merely large cysts of retention, the fluid being sterile? They 
are to be treated either by removal of the fluid-secreting sac or 
by evacuation and drainage, the latter preferably by the vagina. 
When the growths are bilateral, the proper procedure to apply is 
vaginal hysterectomy, with removal of the adnexa. In their evo- 
lution these tumours rip up the peritonaeum from the lateral pelvic 
wall and displace the ureter. The ureter may cross the tumour at 
any point, and must always be identified before the capsule is 
split, otherwise it may be wounded. 

After the enucleation of an intraligamentary tumour the ova- 
rian vessels are to be ligated at the pelvic brim and again at the 
uterine cornu, and the round ligament is to be ligated near the 
pelvic brim. It will usually be found that the ovary and tube 






OVARIOTOMY 267 

have to be sacrificed in trimming away the excess of the capsule. 
After removing the loose flaps of capsule a running suture of 
fine tendon is employed to close the rent in the broad ligament. 
In dealing with a solid ovarian tumour, the growth must, of 
course, be removed whole. If the tumour be malignant, after its 
removal a careful examination of the lumbar and mesenteric 
glands should be made to determine the prognosis. 

In about 15 per cent of cases of ovarian tumour a similar 
process will be found beginning in the other ovary; therefore, in 
all cases of ovariotomy the opposite ovary must be inspected and 
removed if found diseased. 

Ovariotomy is generally one of the simplest operations and 
should be so conducted that normal structures are not wounded. 

After completing the operation, the abdomen is closed without 
drainage. Occasionally cystic growths which have become infected 
will form such universal adhesions to important organs, such as 
the intestines and great vascular trunks, that to remove them will 
subject the patient to an unwarranted danger. In such an in- 
stance, the cyst should be tapped in such a manner as will prevent 
escape of its contents into the peritoneal cavity. After the cyst 
is empty its sac is stitched to the parietal peritonaeum and abdom- 
inal fascia, and the rest of the abdominal wound closed without 
drainage. This will leave the cyst-cavity open for treatment. It 
should be packed with mild iodoform gauze. The intra-abdominal 
pressure rapidly closes the cyst-cavity — so rapidly in fact that the 
gauze packing may be renewed with difficulty. The cyst becomes 
obliterated by granulation and the dressings must be frequently 
changed. 

Vaginal Ovariotomy. — When an ovarian tumour is of a diam- 
eter not greater than 3 inches it may be removed most success- 
fully by the vagina without rupture; and much larger tumours 
may be so removed if they are ruptured to reduce their bulk. I 
prefer the posterior vaginal incision. Upon entering the posterior 
peritoneal pouch the tumour at once presents. Digital examina- 
tion shows the exact relations of the tumour. If it is not ad- 
herent to intestinal coils it is grasped by dull pedicle forceps and 
dragged out of the opening and into the vagina. While holding 
it there the pedicle is perforated by the aneurysm needle and 
two ligatures of stout tendon are drawn through. These are 
locked and tied as high up on the pedicle as the fingers will reach. 



268 GYNECOLOGY 

The pedicle, still held by forceps, is cut through. After inspecting 
the stump to see that there is no bleeding the ligatures are cut 
short and the stump is allowed to recede. The vaginal incision 
is then closed at the sides, a small space being left in the centre 
for a drain of iodoform gauze. 

Over this the vagina is lightly packed with iodoform gauze. 
All dressings are removed and renewed in a week, and the patient 
may be allowed out of bed in two weeks. 

If the tumour fills the pelvis and has formed adhesions to 
important organs, it may be tapped after thoroughly exposing it 
by the vaginal incision, and as the capsule collapses it is drawn 
out of the incision. As the adhesions come into view they are 
readily and safely separated. The pedicle may now be secured, 
the tumour cut away, and the pelvis wiped dry. In every step of 
the operation great care should be exercised to protect the hands 
and ligatures against infection from the anus. This orifice must 
be kept constantly covered by towels, and each time the operator 
touches the field of operation it must be with hands freshly 
cleansed in bichloride-of-mercury solution. 

A safer, more rapid, and neater way of securing the pedicle 
is by means of the curved clamp heated by Skene's method. 
With this all ligatures are dispensed with and a most attractive 
stump produced. Should the ovarian tumour be dermoid in char- 
acter, the utmost care must be exercised in its removal lest it be 
ruptured, for the contents of these growths are often of a most 
virulent nature. Should such an accident occur, the soiled area 
must be carefully cleansed by means of swabs and covered by a 
large pad of iodoform gauze, which is removed onJy just before 
the sutures are tied. 

OPERATIONS FOR ECTOPIC GESTATION 

Abdominal. — Indications. — No matter how extreme the collapse 
of the patient, inasmuch as this is due to the loss of blood and not 
to any form of infection, a ligature must be passed around the 
leaking vessel, and the shock appropriately treated. The abdom- 
inal operation is absolutely indicated in all cases in which the 
foetus is viable, whenever there is lithopaedion, and whenever the 
foetus is too large to pass a posterior vaginal incision without 
morcellation. 



OVARIOTOMY 269 

It is contra-indicated in all cases in which the bleeding has 
ceased, in early cases, and in the intraligamentous cases. 

The Operation. — Uterus curetted. The abdomen is opened in 
the median line. All old clots are turned out with the hand, 
fluid blood wiped away, and any bleeding point sought. This 
should be found, if possible, without placing the patient in Tren- 
delenburg's position lest blood escape into the higher abdominal 
cavity beyond reach. If the case be one of simple tubal abortion 
a portion of the tube only being involved, a ligature should be 
carried around the ovarian artery outside the ectopic sac and all 
the involved portion of the tube cut away. The stump of the 
tube which is left should be treated by a continuous suture of 
chromic tendon, which will unite the mucosa of the tube to the 
peritoneal covering and control the oozing. This will leave a 
patent tube and one which can in future act as an oviduct. This 
conservative procedure is worthy of trial in most cases, for if the 
suture does not satisfactorily control the bleeding a mass ligature 
can then be thrown around the tube. If the tube has ruptured 
near the cornu, the tissues must be ligated upon each side and 
the entire tube taken away. The ovary should never be sacrificed. 
The operation having been completed, if there has been much 
escape of blood, or if there be shock, the peritoneal cavity should 
be douched with a gallon of normal salt solution 110° in tempera- 
ture, wiped dry, and another gallon poured in which is left to 
overcome shock. The abdomen is closed without drainage. The 
tube upon the opposite side should always be examined, for bilat- 
eral ectopic gestation is not very rare, and ectopic of one tube is 
frequently associated with some form of adnexal disease of the 
opposite side. 

If upon opening the abdomen the case is found to be a true 
intraligamentary pregnancy, the vagina should be opened from 
above and the sac entered at its lowest point. After turning 
out the clots a stout drain of iodoform gauze is passed into 
the opening between the folds of the broad ligament and out 
of the vaginal incision. The abdomen is then closed without 
drainage. 

If the pregnancy be advanced and the placenta fully formed, 
the cord should be tied and the foetus removed. The problem then 
presents of the preferable method of dealing with the placenta. 
If the placenta be attached to the tube, the uterus, or the abdom- 



270 GYNECOLOGY 

inal wall, its removal between numbers of ligatures may be at- 
tempted; but if attached to the pelvic floor, to the intestines, or 
to the mesentery, any attempt to remove it is attended by too great 
risk of fatal haemorrhage. If the case be one in which the pla- 
centa is small, the cord may be ligated close to the mass and the 
abdomen closed without drainage, the placenta becoming absorbed 
subsequently. If, however, the placenta be large, an abdominal 
Mikulicz of weak iodoform gauze should be made to completely 
surround the placenta and the gauze lead out of the abdomen. 
As the placenta breaks down it will be taken up by the gauze, 
repeated changes of which will be necessary. If the foetus has 
been dead for a long time, the vessels nourishing the placenta 
may have so far atrophied as to admit of a careful separation 
of the placenta and closure of the abdomen without drainage. 

Whenever the placenta is situated low down in the pelvis, yet 
away from the vagina, this latter should be opened and the pla- 
centa surrounded by iodoform gauze the ends of which are led 
into the vagina. 

During the years 1886 to 1896 the late Dr. E. P. Harris 
found reports of 50 laparotomies in which the foetus was living, 
38 per cent of the mothers dying from the operation, showing 
the great risk attending the operation when the placenta is active. 
Whenever the placenta is large and cannot be safely removed, its 
location may sometimes be isolated from the general peritoneal 
cavity by suturing the sac to the parietal peritonaeum and then 
packing the placental site with iodoform gauze. But at most, all 
operations for advanced ectopic gestation carry a deplorable mor- 
tality. 

Vaginal. — Indications. — In all early cases, whether ruptured or 
unruptured, in all cases of intraligamentary pregnancy, the vaginal 
operation is indicated. 

It is contra-indicated in all cases where the foetus is too large 
to pass the vaginal incision, with one exception. Whenever the 
ectopic of one side is accompanied by destructive disease of the 
other, vaginal ablation of the uterus and adnexa is the safest 
procedure. This may be applied in even advanced cases, provided 
the foetus is not attached high up. Such are the possibilities of 
the vaginal method of approaching this condition in all cases 
where the lesions are pelvic that the author advises that the first 
exploratory stage be performed through the vagina. In 90 per 



OVARIOTOMY 271 

cent of the cases coming to us it will be found that the operation 
can be completed through the vagina. 

The uterus is curetted, cleansed, but not packed. The pos- 
terior cul-de-sac is opened. All blood-clots and fluid blood are 
evacuated and the pelvis wiped dry. The patient is then lowered 
into the author's position and the intestines held up by a gauze 
pad secured by a string. The ectopic tube is sought for and 
brought into the vagina. If the sac be very small, of a diameter 
less than ^ an inch, it is incised along its dorsum and its contents 
carefully scraped out. The cut edges are then united as described 
in salpingostomy. Such early cases are not often met with. After 
carefully and for several minutes studying the amount of oozing 
resulting, the gauze pad is removed and the angles of the vaginal 
incision closed by suture, a small iodoform gauze drain being in- 
troduced between. But if the bleeding is not controlled by the 
suture, and in cases where the sac is over \ an inch in diameter, it 
may be grasped by Skene's forceps and subjected to the electrical 
current sufficiently long to desiccate the stump. The sac is then 
cut away and the vagina closed as before. 

If the pregnancy be intraligamentary an opening is to be made 
into the posterior layer of the broad ligament, the clots turned 
out, and a generous iodoform-gauze drain inserted into the ectopic 
cavity. It is well in all such cases to search also for the small 
foetus or f octal debris. 

If the rupture be an old one, the pelvis being merely filled 
with old clots (intraperitoneal hsematocele), and there being no 
evidence of recent bleeding from the sac, it is not necessary to 
remove the tube. But before adopting such a course the operator 
must be convinced that shrinkage has already begun in the ectopic 
tube, as will be evidenced by its beginning exsanguination. A 
safer course is to remove the tube. Should Skene's apparatus 
not be convenient, the requisite ligatures can with safety be placed 
upon each side of the ectopic mass. 

If the pregnancy has advanced to the formation of a distinct 
placenta, and this is within reach of a vaginal drain, the foetus 
should be taken away and the placental site isolated by a large 
quantity of iodoform gauze. Removal of the placenta through 
the vagina should never be attempted. 

In case an ectopic sac be found upon one side and the oppo- 
site adnexa destroyed by disease, vaginal ablation is indicated. 



272 GYNAECOLOGY 

Whenever a hematocele or placenta is found the vaginal in- 
cision is to be left open without suture; in other instances most 
of the vaginal incision may be closed by suture. 

In view of the absolute safety of the exploratory 
vaginal incision it is to be made so soon as the bare pos- 
SIBILITY OF AN ECTOPIC GESTATION IS ENTERTAINED. It is no 

longer necessary to wait for evidences of haemorrhage and shock 
before arriving at a positive determination of the nature of a 
pelvic mass. 



CHAPTER XV 

CONSERVATIVE OPERATIONS ON THE UTERINE ADNEXA 

It is but a few years ago that for the most trivial reasons 
the ovaries were sacrificed. The unthinking and rash way in 
which those who posed as specialists in the diseases of women 
operated and removed organs which did not conform to some ideal 
in structure which the operator had adopted, very justly brought 
the specialty of gynaecology into disrepute. A better knowledge 
of the physiology and of the pathology of diseases peculiar to 
women have brought about a most radical change in our views 
regarding the propriety of removing the ovaries and tubes. The 
ovaries, at least, have been shown to be most intimately associated 
with metabolism, and the function of menstruation is so inter- 
woven with woman's mental as well as physical life that it is 
conserved even if elaborate and hazardous procedures must be 
adopted to accomplish this as well as cure the patient. This 
change in our opinion, or rather estimation of the value of these 
organs, has been brought about by the unfortunate women who 
were first subjected to mutilating operations; and investigation, 
instead of preceding work of such gravity, has come after the 
failures. The whole trend of modern surgery is to conserve so 
far as possible the physiological activity of the woman by not 
removing any organ at all, but where removal is imperatively in- 
dicated, to effect a permanent and radical cure. The conservation 
of special organs which are diseased must not be carried too far, 
however. There is a broader conservatism which seeks the preser- 
vation of the general health at the sacrifice of even important 
structures. In no field of surgical activity do extraneous circum- 
stances have so much weight as here. Some women prize even 
badly diseased organs more than health, while to others their loss 
is worse than death. These sentiments are perfectly proper, and 
should be given due weight in considering the propriety of a pro- 

273 



274 GYNECOLOGY 

posed operation. The very worst that can be said of conservative 
operations is that they sometimes fail to cure, but they often suc- 
ceed in effecting a cure without mutilation. The latter cannot be 
said about primary radical operations. Eadical work is yet possi- 
ble after conservatism has failed. But conservative operations 
should be employed with as much judgment as the radical, and 
should not be misapplied. The word conservatism should not be 
used as a cloak for neglect to apply the proper treatment. The 
man who adopts the morphine-poultice-douche plan of treatment 
of an acute pelvic peritonitis is not conservative. On the contrary, 
he is largely responsible for any gross lesions which may occur. 
Ignorance is not conservative nor operation necessarily rash. 

It is wise to precede all operations upon the uterus or its 
adnexa by a cleansing curettage. 

Abdominal. — In very many instances of pelvic peritonitis the 
sole sequelas are adhesions which bind together the organs, limit 
their mobility, and interfere with their circulation. To permit 
these false bands to remain is to invite very many disturbances 
in function of the various pelvic organs, and even grave structural 
lesions of the ovaries and tubes. 

In severing adhesiov.s the abdomen is opened in the median 
line. Upon entering the peritoneal cavity digital examination will 
show the degree and extent of the adhesions. It is unwise to sever 
these guided by the sense of touch alone. It is far better to in- 
spect each adhesion before breaking it. To do otherwise is to 
run the risk of tearing the tissues so as to require sutures and 
ligatures to repair the injury. The recent union between the 
viscera can readily and safely be severed by the finger; but when 
the lymph has become fully organized it will not easily break, 
rather will an attempt to do so tear the softer tissues such as the 
tube or intestine. Old firm adhesions are preferably severed by 
means of a delicate pair of blunt-pointed scissors. Even when 
deep in the pelvis they may be seen by employing Trendelenburg's 
position, aided by the proper adjustment of retractors. It is a 
waste of time to sever adhesions between ligatures, for few of them 
have vessels which can produce troublesome bleeding. After they 
are cut, adhesions curl up against the viscus to which they are 
still attached, and ultimately shrink so as to almost disappear. 
After all adhesions are severed the pelvis should be wiped dry 
and the abdomen closed without drainage. 






CONSERVATIVE OPERATIONS 275 

Hydrops folliculi, or cystic ovary, is best treated by simple 
puncture of the cysts where these seem to be superficial. But 
when the greater part of the ovary is the seat of such a change 
the cyst-bearing area should be excised by a V - shaped incision 
which extends through the long axis and down through the free 
border of the organ. The resultant wound is to be closed by 
sutures. Should the bleeding be free, the mattress suture is 
applied; otherwise a running suture of fine tendon will suffice. 
The function of the ovary is maintained if even a very small por- 
tion of its stroma is left. The ultimate results of mere puncture 
of the cysts are poor, the tendency to their formation asserting 
itself in a few months after the operation. The results of excision 
of the cyst-bearing area are far better. 

Corpus luteum cysts are to be treated by incision, not mere 
puncture. The cyst should be cut throughout its long axis. The 
yellow wavy line in the cyst is then seized with toothed forceps 
and the lining of the cyst peeled out from its attachment to the 
ovarian stroma. This leaves loose flaps, which are trimmed. One 
or two sutures of fine tendon suffices to close the wound. 

It is hardly advisable to seek to preserve a portion of an 
ovary the seat of a neoplasm unless this be pedunculate. Occa- 
sionally but a small portion of the ovary will be involved in the 
new growth, but only in very rare instances. Excision of the 
involved area is then indicated only, of course, if the growth is 
benign. 

In no instance of ovarian abscess should conservatism be at- 
tempted, even when the suppurative process appears to be limited. 
If the pus sac is incised and left open it must be drained with 
a certainty of infecting adjacent structures; and it is equally in- 
advisable to close it by suture. Abscess of the ovary invariably 
calls for its sacrifice when approached through the abdomen. 

Hydrosalpinx. — It is seldom that a hydrosalpinx will be met 
with which will necessitate the sacrifice of the entire tube. Even 
if but a small portion near the cornu be uninvolved, it should be 
saved. These retention cysts have sterile contents, and can be 
safely evacuated. The tube should be incised along its free border 
for the entire length of the enlargement. The loose flaps of the 
thin walls are then trimmed away until the normal portion is 
met with. Should small vessels be met with which spout, they 
are ligated. At that portion of the tube where it is intended 
18 



276 



GYNECOLOGY 




the new ostium abdominale shall be, a running suture is so applied 
as to draw the tubal mucosa over to its serosa. If it is found 
necessary to remove the entire tube its mesentery is ligated by a 
series of fine ligatures and the tube tied close to the cornu of 
the uterus. The tube is then cut away. The supports of the 

uterus and the ovary are not interfered 
with. The abdomen is closed without 
drainage. 

When the tube is merely occluded 
owing to peritonitis about its fimbri- 
ated end, the operation of salpingos- 
tomy is to be performed (Fig. 122). 

The free border of the knobbed and 
occluded fimbriated end is split with 
scissors for about 1 inch. The in- 
verted fimbriae are then turned out 
and the cut edge of the mucosa is 
united by a running suture to the 
serosa. Even if the contents of the 
tube be milky, not purulent, and 
there be no evidences of an acute 
process, this operation is indicated. 
Little benefit is derived from the oper- 
ation when the tube is in a condition 
of sclerosis, as pachysalpingitis. In order for the tube to act as 
an oviduct its peristalsis must be restored. Merely establishing 
a new ostium abdominale does not do this, and salpingostomy is 
useless unless the muscular coat of the tube be normal. It may 
therefore be stated that all chronic tubal lesions due to a primary 
salpingitis contra-indicate salpingostomy, but where the lesions are 
merely sequelae of a pelvic peritonitis the operation is often indi- 
cated. The abdomen is closed without drainage. 

If acute salpingitis exists, or a pyosalpinx be present, conserva- 
tism, as applied through the abdomen to either condition, is out 
of the question. To open such a tube is to expose the pelvic 
peritonaeum to its filthy contents without providing means for 
the inflammatory products to escape. 

In ectopic gestation involving the tube much can be accom- 
plished by conservative work in many cases. The rule is to sacri- 
fice only so much of the tube as is implicated in the ectopic sac. 



Fig. 124. — Salpingostomy, or 
the Construction of a New 
Opening in an Occluded 
Fallopian Tube. 



C, cornu uteri ; 0, ovary 
lopian tube. 



T, Fal- 



CONSERVATIVE OPERATIONS 277 

There will usually be found at least a portion of the tube which 
is free from invasion, and though this be highly coloured and 
very vascular, it will involute after the ectopic sac is cut away. 
The tubal mesentery is ligated by a series of ligatures to the 
point at which the tube is to be cut off. Here a ligature is thrown 
around the tube and twisted, not tied. The tube is then cut away 
and the twisted ligature loosened sufficiently to allow the vessels 
to reveal their presence by bleeding. If only a few of these show 
they are tied, and if there be a parenchymatous bleeding con- 
tinuing, the attempt should be made to control it by a running 
suture. Should the cut tubal walls continue to bleed the ligature 
which was thrown around the tube is tied, the operator abandon- 
ing all attempts to leave an open ostium ab dominate. Whether 
subsequently a tubal stump so treated becomes patent, I cannot 
say, but from experience with other conditions we are warranted 
in stating that such a result is possible. 

This conservatism is applicable only when the ectopic sac is 
small and when speed in operating is not rendered necessary be- 
cause of great loss of blood and shock. The abdomen is closed 
without drainage. 

A prolapsed, even though adherent, ovary should not be re- 
moved. It is to be freed from all false attachments and lifted 
up to the level of the cornu of the uterus. A fine tendon suture 
is then passed through the mesentery of the ovary, and again 
through the insertion of the ovarian ligament into the uterus. 
Upon tying this the ovary is drawn up and becomes attached by 
the plastic lymph which is effused about the suture. The mesen- 
tery of the ovary is selected for the passage of the suture because, 
though highly vascular, it is of firmer texture than the ovarian 
stroma proper. 

The abdomen is closed without drainage. 

Vaginal. — It has been seen that there are certain cases of tubal 
disease which are treated by removal only when approached by 
the abdomen. The reason for this is that drainage would be neces- 
sary to prevent serious accidents, and along the track of the ab- 
dominal drain intestinal and ventral lesions of importance would 
occur. But by operating through the vagina drainage can be em- 
ployed without harm resulting, and therefore certain purulent 
accumulations in the adnexa are amenable to the conservative 
vaginal operation while denied similar treatment through the ab- 



278 GYNECOLOGY 

domen. It may, however, be fairly stated that whenever compli- 
cated ligation or suture of tissue is needed the vaginal operation 
is contra-indicated owing to technical difficulties. 

Hydrosalpinx is treated with perfect ease and success through 
a vaginal incision. The tube is split along its dorsum and the 
loose anaemic flaps trimmed away. To accomplish this, after the 
tube has been freed from adhesions it is drawn into the vagina 
and held there by a delicate ovarian forceps. After wiping away 
all fluids the tube is returned and the edges of the incision are 
closed by tendon sutures except at the middle, into which a wick 
of iodoform gauze is introduced. The vagina is packed with 
gauze. The cul-de-sac drain is removed in a week and renewed, 
and the patient allowed out of bed with a snug supporting vaginal 
dressing of iodoform gauze. In five days the second cul-de-sac 
gauze is removed and is not renewed, but the vagina is kept packed 
until the incision closes tightly. 

If there be adhesions between the pelvic viscera, these are 
readily broken up through a vaginal incision and under the guid- 
ance of the eye if the patient be thrown into my position. The 
longer adhesions may be caught up with a blunt hook and held 
while being severed with scissors. The angles of the incision are 
closed and a slender drain of gauze inserted, as above described, 
if there be much oozing ; but if there be no parenchymatous bleed- 
ing, the entire incision may be closed after wiping the pelvis dry. 

If the tube be merely occluded, a salpingostomy is to be per- 
formed in the same manner as through an abdominal incision. 
The vaginal incision is to be only partially closed, as it is im- 
possible to positively know whether the contents of an occluded 
tube are sterile. 

If a tubal ectopic sac exists which can be treated conservatively, 
the vaginal method of operating is inferior to the abdominal in 
certain cases and superior in others. In the advanced cases the 
tube is drawn down into the vagina and seized with Skene's curved 
clamp. After desiccating it the sac is cut away, and no ligatures 
are necessary. The pelvis is wiped dry and the vagina closed. 

In the very earliest cases the tube is opened along the free 
border and the tubal contents curetted out. If there be much 
oozing the tube is either treated by Skene's method or ligated and 
cut away. But in certain of these very early cases, when the tube 
is opened and curetted, the oozing is slight and the tube can be 



CONSERVATIVE OPERATIONS 279 

returned without ligature or suture. In such an instance the 
angles of the vaginal incision only are closed and the centre is 
drained by gauze. 

Owing to the exceeding friability of these ectopic tubes sutures 
are not readily placed in them through a vaginal incision, but 
owing to the ready escape of blood through the open centre of the 
vaginal incision much can be left to nature in the way of con- 
trolling parenchymatous bleeding. 

The strongest claim which the vaginal method of operating has 
to our consideration is in the treatment of acute salpingo-oophor- 
itis and acute pelvic peritonitis. 

If the uterus has not been previously curetted this is now 
done (see Curettage). If curettage has been done some days be- 
fore, the uterus is simply irrigated with boric-acid solution. Upon 
opening the posterior cul-de-sac serum and lymph-flakes escape. 
The finger is inserted into the cavity behind the uterus, and pro- 
ceeding towards the lateral pelvic walls all the tender lymph planes 
are easily severed by the finger. The tubes are freed from their 
attachments to broad ligament or viscera and gently brought to 
the vaginal vault for inspection. It is not a difficult matter to 
open the fimbriated ends with any blunt instrument, the tubes 
being held by ovary forceps. A strip of iodoform gauze is in- 
serted into the tube to the uterus. This is left in place until the 
operation is over. A small amount of fluid may escape from the 
tubes, clear or cloudy. It is now proper to wipe the pelvis dry. 
The ovaries are palpated and loosened from adhesions. The oper- 
ator makes his investigation of the broadest kind. Xo false attach- 
ments between the organs should be overlooked. Every lymph 
plane should be entered and broken up. Convinced that the tubes 
are open and that no organs have been left matted together, the 
gauze pads are removed, the pelvis is carefully wiped dry, and the 
strip of gauze in the tube is withdrawn. The uterus is packed 
with iodoform gauze. Into the opening in the cul-de-sac strips 
of iodoform gauze are inserted so as to snugly fill the opening. 
These extend up behind the uterus to the level of the internal os. 
The uterus, carrying with it the dressings, is then lifted up into 
its normal position in the pelvis, and the vagina is packed with 
gauze. In two days the vaginal and uterine packings are removed 
and the vagina again packed. The cul-de-sac dressing can usually 
remain for a week. It is then removed and renewed. The dress- 



280 GYNECOLOGY 

ings are renewed about once in five days until the wound closes. 
In this operation the surgeon seeks to open the lymph streams and 
tubes so as to cause them to leak. This he would not dare do 
had he not provided through his gauze a means of escape for the 
discharges. 

There no longer being a necessity for locking in infection, the 
tissues do not attempt it. The curetting having cut short the 
source of infection, no fresh supply is furnished. The causative 
focus in the uterus has been removed and the complications at- 
tacked by evacuation. The question is suggested, Does not lymph 
form about the gauze in the cul-de-sac? Undoubtedly; but I 
wish to call attention to the difference between the character of 
the lymph which forms about an absorbent antiseptic dressing and 
that which is the exponent of infection. The first is not accom- 
panied by pain, by fever, nor by pus ; it is evanescent and produces 
but few bands of adhesions, and these not permanent. Further- 
more, it is limited to the cul-de-sac and does not implicate the 
tubes. Lymph the result of infection is absolutely different. Its 
production is accompanied by fever, by occlusion of the tube, by 
thickening of the ovarian capsule, by great pain; and it is perma- 
nent or else results in the stoutest kind of adhesions. Moreover, 
it is extensive in its distribution. The operation is the counterpart 
of another where the infected focus is cleaned out and the limb 
above incised to permit the escape of the products of the progress- 
ing infection, as in cellular infection of the hand and arm. In 
very many cases I have done this operation, and never have I 
failed to check the process. The operation goes a step further 
than curettage. It is not only conservative, but is curative. To 
deny it to the woman is to refuse to believe that her most highly 
vitalized organs have power of repair when aided by incision and 
drainage. It is absurd to state, as some do, that there is nothing 
between the let-alone policy of the midwife and the mutilating 
operation. From the moment the adnexa are attacked by infec- 
tion, evacuation and drainage govern us. This operation becomes 
in the hands of the practitioner the means by which he prevents 
suppuration, and by applying it early he cures his cases perma- 
nently. It certainly takes some courage to come from behind 
the protection of the hypodermic syringe and thrust oneself into 
the position of responsibility for the result. Morphine, the poul- 
tice, and hot douche but lull the patient into a state of insensi- 



CONSERVATIVE OPERATIONS 281 

bility to her danger. To apply these is to do nothing; to replace 
them with this operation is to speedily and permanently cure these 
patients. Xot the least attractive attribute of the operation is the 
ease with which it may be done. It is entirely free from danger. 

Chronic Pelvic Suppuration. — In cases of long-standing pelvic 
suppuration, cases which can so often be designated as diffuse 
pelvic suppuration, either radical or merely palliative operations 
may be applied through the vagina. It matters not whether the 
pus is in the tubes or ovaries or has burrowed between the ad- 
herent organs. In these cases the operator, because of extraneous 
circumstances or because his patient is too ill to bear a radical 
operation, decides to evacuate the pus. This he does in such a 
manner as, combined with the skilful application of his dressings, 
will secure obliteration of the pus sacs. This result is obtained 
by the production of connective tissue, and the case is converted 
into one very similar to that designated as genital sclerosis. And 
whereas patients so treated often suffer from dysmenorrhea and 
pelvic pain, they continue to menstruate, and have none of the 
disagreeable symptoms attending the artificial menopause. It is 
my experience that when pus sacs have become converted into 
mere connective-tissue masses, suppuration in them does not often 
again occur. 

The merely palliative operation is positively contra-indicated 
when the suppuration is due to tuberculosis. 

The patient is placed under general narcosis and in the lithot- 
omy posture. The uterus should be curetted and swabbed out. 
The operator then grasps the cervix with blunt traction forceps 
and holds it up while he makes the posterior incision through the 
vaginal tissues. The uterus is usually so fixed that it cannot be 
pulled down, so the operator enters the peritoneal pouch rather 
high up. In making this breach into the peritoneal cavity the 
index finger far surpasses all instruments. After entering the 
cavity the finger is worked up behind the uterus and upon each 
side seeks out the pus pockets. If these can be broken into with 
the finger it should be done, but if too tough for this, closed scis- 
sors may be employed for the purpose. As each cavity is emp- 
tied the opening is enlarged with the fingers. Xo attempt is 
made to break up the isolating dome of adherent organs which 
lie above those inflamed, nor should irrigation be employed lest 
pus be washed through a small opening into the higher and more 



282 GYNECOLOGY 

important peritoneal cavity above. The purulent cavities are 
merely sponged dry. Each cavity is then carefully packed with 
5-per-cent iodoform gauze, and the pelvis as well is drained by 
the same material. The dressings are removed and renewed as 
often as needed, and not a little skill is required to adjust them 
so that the suppurating cavities will not close too soon. We have 
found by bacteriological examination that the dressings sterilize 
the field of operation. After healing is completed the local treat- 
ment should be by tampons of ichthyol (10 per cent) applied 
twice a week. 

The operation is applicable to either unilateral or bilateral sup- 
puration, and is the one I almost always apply to the exclusion of 
all others in pelvic suppuration in young women. It is not to be 
confounded with the old trocar puncture and drainage-tube treat- 
ment. If the trocar did not find pus it was no evidence that pus 
did not exist, and if pus was found, the treatment did not prevent 
its recurrence. The trocar puncture was a blind procedure and 
violated one great surgical rule in that it merely evacuated pus 
without obliterating the cavity in which it formed. Over 50 per 
cent of cases of pelvic suppuration treated as described are so 
much relieved that they refuse a subsequent radical operation. 

ABDOMINAL SALPINGO-OOPHORECTOMY 

Salpingo-oophorectomy is the removal of the ovary and tube, 
and may be performed upon one or both sides. It is indicated 
in all cases of tubo-ovarian disease in which conservatism is not 
possible. It is also much used as a palliative method of treatment 
in uterine fibro-myomata. I regret to state that the operation is 
also performed to induce artificial menopause, in the mistaken 
belief that menstruation has a certain causative relation to epi- 
lepsy, hystero-epilepsy, nymphomania, and other neuroses. 

An ovary and tube may be removed by a lateral incision over 
the affected side, or by a curved suprapubic incision, or through 
the median abdominal" incision. As a rule, the last is the proper 
route, as through it both sides may be attacked with the greatest 
ease and previously undiscovered complications more readily cor- 
rected than through any other abdominal incision. 

The technique of the operation varies somewhat with the 
lesions. 



SALPIXGO-OOPHOBECTOMY 283 

Normal Salpingo-oophorectomy. — The removal of normal ova- 
ries and tubes is no longer countenanced except for two conditions. 
It is done to prevent future pregnancies in a case which is being 
subjected to Caesarean section, but even here other operations are 
preferable because not necessitating the sacrifice of the ovaries. 
Among gynaecological procedures the only legitimate application 
of the operation under discussion is for the purpose of checking 
the further growth of fib r o -my o mat a uteri. 

The incision into the peritonaeum should be only long enough 
to admit two fingers. Upon opening the abdomen one ovary and 
tube are held up in the incision so as to make the infundibulo- 
pelvic ligament stand up from the pelvic brim. In this band of 
peritoneal tissue lie the ovarian vessels, and when they are lifted 
up in this manner they are removed from the ureter which lies 
beneath them. The operator passes a blunt pedicle needle armed 
with medium chromic tendon and ties the ligature with care. 
Another ligature of similar character is passed around the ovarian 
ligament and Fallopian tube far enough from the cornu of the 
uterus to miss the round ligament. The ovary and tube are then 
cut away, enough tissue being left to prevent the ligatures slip- 
ping. Two ligatures upon each side will suffice. If small veins 
in the cut broad ligaments bleed they may be separately caught and 
tied. It will be observed that the ligatures are all tied independ- 
ently of each other. The locked ligature is unsafe, as it renders 
slipping from one stump easy, thus causing secondary haemorrhage. 
After inspecting the pelvis and wiping it dry, the abdominal 
wound is closed without drainage. 

Simple Retention Cysts. — The various forms of hydrosalpinx 
and tubo-ovarian cysts may be so classed. Inasmuch as these 
accumulations, although of inflammatory origin, are free from 
germ life, the possibility of conservatism must be eliminated be- 
fore their removal is decided upon. The tube and ovary are 
usually found low down in the pelvis and adherent to the pos- 
terior face of the broad ligament. They are gently freed and 
brought up into the incision. In doing this much care is necessary 
because the cyst-walls are exceedingly thin. If ruptured during 
the manipulations no harm will be done except that it is more 
difficult to handle them when they are collapsed. After the organs 
are thoroughly freed the ovarian vessels are ligated. The oper- 
ator then passes a ligature around the ovarian vessels just below 



284 GYNECOLOGY 

the attachment of the round ligament, where it may be felt pul- 
sating. This he now ties. The tube is then cut out of its inser- 
tion into the uterine wall, and the tube and ovary cut away from 
their other attachments (see Fig. 125). Two sutures are now 
employed to close the V-shaped incision in the cornu of the uterus, 
and a running suture closes the rent in the broad ligament. The 
abdomen is closed without drainage. 

In Pyosalpinx and Ovarian Abscess. — Median Abdominal In- 
cision. — In removing a purulent focus from one side, the first 




I 



BL 



J. 



Fig. 125— Bovee's Method, and the only Proper One, of removing a Pits-tube. 

A, ligation of the ovarian vessels of the pelvic brim ; 2?, ligation of the ovarian artery in 
continuity beneath the Fallopian tube, where it anastomoses with the uterine ; BL, 
bladder ; Ut, uterus. 

essential step is freeing the omentum and intestines from all ad- 
ventitious attachments in the pelvis. They are then held back by 
gauze pads which circle the pelvic brim from one loin to the other. 
The incision should be made long enough to permit a thorough 
inspection of the pelvic contents when the edges of the incision are 
retracted. The vast majority of these inflammatory growths lie 
behind the broad ligament and low down. To free them the 



SALPINGO-OOPHORECTOMY 285 

operator introduces one finger down behind the uterus, and by 
means of a sawing, lifting motion he peels the ovary and tube 
away from the broad ligament and pelvic floor. The reason he 
can do this is because the attachments have formed not between 
raw surfaces but between masses of plastic lymph. The greatest 
difficulty will be experienced in this step when the fimbriated end 
of the tube is reached, for there the peritonitis was most intense. 
If the lesions have been caused by streptococci, the lymphatic 
glands beneath the peritonaeum may have broken down, and then 
is produced both intraperitoneal and retroperitoneal suppuration 
about the pelvic brim, distorting the anatomy by lifting up the 
ureter and rendering enucleation most difficult. In such a case 
one or the other pus pocket may be broken into. As the tube 
and ovary become somewhat freed, the operator may employ 4 
fingers in effecting the liberation of the adnexa. Whenever a 
pus pocket is broken into the parts are wiped dry by iodoform 
gauze and the operator cleanses his hands anew in lysol and 
bichloride solution. When this accident happens, the advantage 
of placing a dam of gauze pads about the pelvic brim becomes 
apparent. However great the difficulties encountered in" 

THE LIBERATION OF A PUS-TUBE OR OVARY, NO ATTEMPT AT LIGA- 
TION OF VESSELS SHOULD BE MADE UNTIL THE SEVERAL VASCULAR 

points are fully identified. The operator should have the en- 
tire field of interference exposed for unobstructed inspection. He 
should be able to identify the fundus uteri, the round ligament, 
the tube at its insertion into the uterus, and the important anato- 
my at the bifurcation of the common iliac artery. A careful con- 
sideration of all the anatomical structures, as well as of the lesions 
which mask their regional association, is of prime importance be- 
fore any attempt is made to free the diseased structures or to apply 
ligatures. The operator is much aided in his work after he has 
liberated the omentum and small intestines from all false attach- 
ments in the pelvis, if he will drop the patient into Trendelenburg's 
position sufficiently to prevent the respiratory movements and 
intra-abdominal pressure forcing the intestines into the field of 
interference. After the ovary and tube are thoroughly liberated 
so that they are attached by their anatomical relations only, the 
first ligature of medium chromic tendon is applied to the ovarian 
vessels. This should be outside the involved field if possible. This 
ligature is tied and its ends cut short. The ovarian artery is then 



286 GYNAECOLOGY 

sought along the side of the uterus and is secured by passing 
around it a curved aneurysm needle, which is made to draw a 
medium chromic-tendon ligature through. Upon tying this latter 
the blood supply to the ovary and tube is cut off, and these organs 
may be removed (see Fig. 125). It is well to save the round liga- 
ment, if that be possible, but in certain old cases it is impossible to 
separate the tube from the ligament. In such a case it will be 
necessary to ligate the round ligament separately. The union be- 
tween the tube and the posterior face of the broad ligament is not 
so difficult to separate, but attachments between the pus sac and the 
rectum are usually most firm. The suppurating tube has a weaken- 
ing effect upon the intestinal wall, and therefore the liberation of 
the tube from the rectum must be most carefully effected. If a 
communication once existed between the intestinal and tubal cavi- 
ties, the separation of the tube may be impossible without breaking 
into the intestine. If that accident occurs, the enucleation and 
removal of the pus sac must be rapidly completed, and the necrotic 
edges of the intestinal fistula trimmed and closed by two tiers of 
interrupted sutures of fine chromic tendon. In such a case the 
sphincter ani must be rendered incompetent by forcible dilatation so 
as to permit the freest escape of gases. Such wounds in the rectum 
readily heal. After removing the diseased tube and ovary a careful 
inspection of all parts of the pelvis is to be made. Bleeding from 
broad surfaces is usually parenchymatous. It may be checked by 
dipping a gauze sponge into very hot saline solution and applying 
it to the oozing surface for a few moments, or by lightly touching 
it with tincture of iodine. Most of the bleeding coming from 
a pronounced point will be found to be venous, but all such 
points should be ligated. After all bleeding has ceased iodoform 
gauze should be applied against the raw surfaces and left there 
during the application of the sutures. Before beginning this the 
operator should carefully cleanse his hands as well as the edges 
of the wound. The abdomen is closed by interrupted sutures 
applied in two tiers. Before tying the sutures all the gauze is, 
of course, to be removed and the omentum pulled down into 
place. If a large pus sac is ruptured during its manipulation and 
its contents scattered over the intestines the greater part of the 
pus can be wiped away, but along the mesenteric folds unseen 
quantities may be hidden. If the patient is in Trendelenburg's 
position when this accident occurs she should at once be lowered 



SALPINGO-OOPHOKECTOMY 287 

to the horizontal, and the pelvic and abdominal cavities irrigated 
by gallons of saline solution, one hand being employed to move 
the intestinal coils back and forth so that all parts of them may 
be washed. As the saline solution wells up and out of the wound 
it will be seen to carry out the flakes of lymph and pus. After 
irrigation is complete the abdominal cavity and the pelvis are 
thoroughly dried, and the operation carried to completion. The 
irrigation of the pelvis and abdomen accomplishes much. It has, 
for instance, been shown that saline solution is mildly antiseptic, 
and that it is not damaging to the tissues. It further so dilutes 
the pus that it becomes inert, and it also facilitates its ready ab- 
sorption by the peritonaeum. 

If the vermiform appendix is found adherent to the inflamed 
mass it should be removed, preferably by inversion if that be 
possible. 

In no instance should an abdominal drain be employed after 
removing a pus focus from one side. If the operator has been 
unable to check all oozing, or fears that a point of suturing in 
the rectum may give way, he may open the posterior cul-de-sac 
and pass a drain of iodoform gauze down into the vagina. 



CHAPTER XVI 

MANAGEMENT OF PATIENTS WHO HAVE BEEN 
SUBJECTED TO CELIOTOMY 

There are three phases to this. Of most importance is the 
general treatment, that directed to the wound and the peritoneal 
cavity not demanding the attention necessary in preantiseptic days. 
The most immediate distress comes from nausea, and as the vom- 
iting strains the wound it should be minimized. Those with 
dilated stomachs and those who are obese are more comfortable 
with a pillow under the head. As a rule, spare patients vomit less 
if their heads are low. The nausea is in all cases somewhat less- 
ened by the inhalation of the fumes of vinegar upon a handker- 
chief and by a small ice-bag over the xiphoid. Very dry cham- 
pagne and cracked ice allays vomiting. It may be given in 
-J-ounce quantities every half hour or hour, beginning four hours 
after the operation. If the tongue be furred and the case septic, 
-J-ounce doses of iced water with 5 drops of lemon-juice will 
lessen vomiting. The imbibition and injection of water before 
operation has done away with much of the post-operation thirst; 
but in emergency cases, where preparation is impossible, the thirst 
may be diminished by the acidulated water mentioned, and par- 
ticularly by rectal enemata of 8-ounce quantities of normal salt 
solution given every four hours. The patient is comforted by 
holding an iced cloth to her lips. It is unspeakably cruel to with- 
hold water for the first day. It is perfectly safe in most cases 
to begin the acidulated water in four hours. However, if the 
stomach be particularly irritable, it is better to keep it quiet. 
The pain suffered is not so severe as many patients represent it. 
The loudest outcries are by women who have been taught the 
use of morphine. It is my practice to withhold morphine unless 
the unreasonable conduct of the patient compels me to satisfy her 
288 



MANAGEMENT OF PATIENTS AFTER CCELIOTOMY 289 

craving. I then give, and only when I am compelled to do so, 
| of a grain of codeine with T fo of a grain of hyoscyamine. 
Opium relaxes the pylorus and allows bile to regurgitate into the 
stomach, thus producing vomiting. The matter vomited after 
ether is usually glairy mucus, after opium it is bile-stained. 
This drug also paralyzes the intestines, thereby conducing to re- 
tention of faeces, tympanites, and sepsis. Active intestinal peri- 
stalsis is inimical to infection of the peritonaeum. The relief af- 
forded by opium is but a borrowed ease, to be paid back later by 
much vomiting, enemata, thirst, etc. It further produces in many 
a very fair imitation of the symptoms of infection, as high pulse, 
tympanites, and temperature from retention-poisoning. 

If the patient has had a careful preparation it is not necessary 
to seek an early catharsis, but if the preparation has been insuffi- 
cient, or tympanites sets in, I try to secure a movement during 
the second day. The patient is raised upon two pillows and is 
given from 4 to G ounces of cold Eubinat Condal water, or 120 
grains of Glauber's salts in a gill of water. If the stomach be 
irritable she is turned on her right side before drinking the 
laxative, and is kept there for half an hour. The laxative will 
then run into the intestines. Two hours after taking this she 
is given a low enema of glycerin 1 ounce and soap-suds 8 ounces. 
The practice of actively purging all cceliotomy cases as soon as 
possible is irrational. It is sufficient to see that the intestinal 
peristalsis is established and retention-toxicosis prevented. In- 
testinal gases can find a ready escape, and thus the patient be 
made more comfortable, if a rectal tube be inserted and left in 
the rectum about half the time. 

If there be no special contra-indi cations the patient may void 
urine, but unless she can easily do so every six hours the catheter 
should be used. If the patient is allowed to void urine she should 
not be raised upon the bedpan, as this makes the abdominal mus- 
cles tense and gives pain, but she should pass it directly into 
a urinal. In most cases the catheter will be required. The hour 
of catheterization, the quantity of urine secured, and its com- 
plete analysis should be noted. The higher the specific gravity 
of the urine, associated with diminished quantity, the greater the 
patient's danger. The most important function to be watched is 
that of the kidneys. Therefore, whenever possible, the specific 
gravity must be kept down and the quantity maintained by the 



290 GYNECOLOGY 

early taking of water and by saline enemata. I have found that 
the rational use of hydrotherapy enables my patients to excrete 
an average of 32 ounces of urine the first day. 

The first food given is usually at the end of one day, unless 
early catharsis seems indicated, when food is withheld until the 
bowels move. A little of the expressed juice of broiled steak or 
chicken broth, or the white of one egg beaten up with ice and 
the juice of an orange, may be tried. A feeding of 2 ounces of beef 
juice alternating every six hours with good chicken broth will 
suffice for the first two days. I never give milk or kumyss or 
other prepared foods. On the third day toast and a little scraped 
beef may be allowed. 

I have never insisted upon a strictly dorsal position. The pa- 
tient can with perfect safety be propped a little upon the right 
side, thus diminishing nausea and giving her back a rest. Of 
course, if drainage is employed the dorsal position must be main- 
tained. I keep all my cases of laparotomy in bed at least three 
weeks, and often longer, to diminish the liability to hernia. 

The pulse, respiration, and temperature (rectal) should be 
taken every four hours and recorded. Mouth temperature is not 
reliable. If the patient has had a cold drink or breathes with 
her mouth open, the temperature is lowered, etc. Besides, ton- 
silitis is communicated by mouth thermometers. I consider a 
rectal temperature of 99.3° F. normal. If the temperature jumps 
up in a few hours after operation if is traumatic and causes no 
uneasiness, but when it begins on the second day to rapidly ascend, 
it is due to some complication. The pulse, temperature, and urine 
show more than any three factors how the case is progressing. 
If tympany persists, salol in 2-grain capsules every two hours will 
lessen it. If the pulse flags merely from weakness, strychnine in 
moderate doses, champagne, or a little brandy and Apollinaris 
will revive it. Throughout the entire treatment much comfort 
will come to the patient, and the case be conducted smoothly, if 
firmness and gentleness guide surgeon and nurses. Sick women 
are strikingly like sick children, and are best handled when en 
rapport with their attendants. 

If the sutures give no distress they may be left in for three 
weeks. I have thought that their presence had a restraining in- 
fluence upon the impatience of some. 



MANAGEMENT OF PATIENTS AFTEK CELIOTOMY 291 

COMPLICATIONS AFTER CCELIOTOMY 

Secondary Haemorrhage. — Of all the complications of intra- 
peritoneal operations, the three most serions and nsnal are sec- 
ondary haemorrhage, sepsis, and ileus. In these days of ligation 
in continuity rather than en masse, secondary haemorrhage is not 
often seen. It may occur soon after the operation or as late as 
the third week. The bleeding may be from a vessel in the wound 
of incision or from a large vessel severed in the abdominal cavity. 
If the haemorrhage comes from the external wound the dressings 
are soon saturated, and this will attract the attention of the nurse. 
If the bleeding be more than was expected, the dressings are at 
once removed and the vessel sought for. It is important to deter- 
mine whether the blood comes from the abdominal incision or from 
the cavity. If it arises from a neglected vessel in the incision there 
will usually be found a subcutaneous haematoma, and the blood be- 
neath the dressings will be clotted ; whereas if the dressings are wet 
by blood which has escaped within the abdomen, this cavity must be 
filled to a degree of tension before the blood can be forced between 
the sutures, and severe shock is then present. Furthermore, the 
blood escaping externally is fluid, and does not readily clot. The 
removal of a few sutures over the haematoma will expose the 
responsible vessel. Haemorrhage from an intra-abdominal vessel 
alone demands serious consideration. It usually begins shortly 
after the patient is returned to bed, to become most severe in a 
few days when the calibre of the vessel is fully established. It is 
seen in ^ per cent of all laparotomies. The problems involved in 
the tying of vessels cannot be debated here, and the reader is re- 
ferred to the masterly work of Ballance and Edmunds on Liga- 
tion in Continuity. The symptoms of secondary haemorrhage are 
plain. The patient becomes paler, the pulse rises in speed, and 
becomes compressible or disappears. As the brain feels the loss 
of nourishing blood the face becomes anxious, the pupils dilate, 
a cold sweat breaks out, the patient looks frightened, and soon 
becomes restless; occasionally severe abdominal pain occurs, with 
vomiting. The respiration becomes sighing, then gasping. Sub- 
normal temperature, due to empty capillaries, is present. As 
death approaches cardiac pain is severe. As soon as haemorrhage 
is detected, the patient should be placed upon the operating-table 
in Trendelenburg's position and kept there until the operator is 
19 



292 GYNAECOLOGY 

ready to open the wound. This position lessens the bleeding and 
relieves the disagreeable symptoms due to cerebral and cardiac 
anaemia. While in this position a high saline enema of 2 quarts 
and at 110° F. is to be given. When the wound is opened under 
chloroform all clots are turned out, the leaking vessels secured, 
the peritoneal cavity filled with normal salt solution, and the 
abdomen closed. An intravenous infusion of from 4 to 6 pints 
of saline solution should be given slowly. The patient is put to 
bed, well covered, and surrounded by artificial heat. The best 
heart stimulants are brandy and strychnine given in small doses 
frequently repeated. Nourishment should begin as soon as the 
stomach will retain it. 

Sepsis after Operation. — Wnenever there is a rise in tempera- 
ture after operation, it is the duty of the surgeon, if possible, to 
positively identify its cause. Soon after the promulgation of 
Lister's method of treating wounds, we believed that all tempera- 
ture after operation indicated septic intoxication, but since the 
routine enforcement of certain rules in our hospital wards, we 
have discovered that very many injuries which do not break the 
surface produce a rise in temperature, for instance, fractures of 
the thigh. Hence we speak of traumatic temperatures. We often 
see such temperatures after a prolonged and difficult operation in 
which there has been much bruising of tissue, and even after an 
examination under general narcosis. A rise in temperature due 
to this is sudden and occurs almost immediately after the opera- 
tion, but very rapidly subsides without treatment, and need give 
no alarm. Another form of post-operative fever is due to the 
retention of putrefying faecal masses in the intestines, or to the 
retention of blood-clots either within the uterus or the peritoneal 
cavity. If due to the first cause, there are present abdominal pain, 
tympanites, etc. If due to blood in the peritoneal cavity, such, 
for instance, as in ruptured ectopic gestation, the temperature 
rises but little unless the blood becomes infected; but some of 
the symptoms of peritonitis of the simple plastic type may be 
present, such as fixation of the organs, etc. When the escape of 
blood has communicated with the atmosphere, it takes on putre- 
factive changes, therefore we find that blood penned up in the 
uterus produces a disagreeable odour. All of these temperatures 
due to retention of putrefying or even dead material are very 
properly described as cases of " retention toxicosis." When the 



MANAGEMENT OF PATIENTS AFTER CELIOTOMY 293 

temperature is, however, clue to the toxines produced by the pus- 
causing organisms, we speak of it as septic intoxication. In other 
places the various forms of diseases causing this are discussed. 
It is sufficient now to describe sepsis occurring after operation. 
If the sepsis has resulted from a plastic operation the wound 
should be very carefully examined, and if evidences of infection 
are present the sutures in the centre of the involved area should 
be at once removed and the edges of the wound separated suffi- 
ciently to allow of irrigation of the wound. It may be the infec- 
tion will be about one suture only, but sufficient sutures must be 
removed to enable the operator to wash out the wound and apply 
his dressing, even if all must be removed. A dressing which was 
devised by the late Professor Van Arsdale has no equal. For 
instance, assuming the infection to be in the surface of the wound 
of laparotomy — and most of them are between the skin and fascia 
— enough sutures are removed to expose the involved lips, and after 
all pus is washed out and the edges of the wound irrigated with 
normal salt solution, the wound is thoroughly dried. Into such 
a cavity gauze soaked in a mixture of balsam of Peru 1 part and 
castor oil 8 parts is introduced, and the whole covered with rubber 
tissue. This dressing should be renewed every day. Bacteriolog- 
ical examinations of many thousands of cases have shown that 
even the most virulent types of streptococcic infection have been 
controlled by this simple method of treatment. If the infection is 
in the cervix after an amputation, all sutures should be ripped out 
and the surface painted with pure carbolic acid and the vagina 
packed with a strong iodoform gauze. If after perineorrhaphy 
the wound becomes infected, sufficient stitches must be removed 
to allow of irrigation. In short, surface infections are to be 
treated by evacuation and drainage, and the application of such 
sterilizing preparations as have been found appropriate to the 
location in which the infection has taken place. 

Septic peritonitis occurring after laparotomy is one of the 
gravest of complications. It may come on within twelve hours 
after the simplest operation, but usually manifests itself after the 
first day. The virulence of an attack depends not only upon the 
amount of the infecting agent introduced, but also upon the de- 
gree of trauma inflicted and the general condition of the patient. 
One marked distinction between the true sepsis and the other 
fever-producing conditions is in the rapidity of the pulse accom- 



294 GYNAECOLOGY 

panying sepsis. Taking a septic case in which the symptoms 
rapidly supervene, we find that the patient having been returned 
to bed in an excellent condition with a pulse less than 100 and a 
temperature of 100.2° F., does not rally as she should. The oper- 
ator knowing every detail of his operation and thoroughly con- 
versant with the patient's general condition before the operation, 
is surprised to find the temperature and pulse speedily rise, so 
that perhaps in twelve hours after the first disagreeable symptoms 
the patient will present the following appearance : temperature, 
103.5° F. ; pulse, 140; surface of the body cold, face pinched and 
anxious, urine markedly decreased and reacting to the peptone 
test. If the blood is examined, exaggerated leucocytosis is usually 
present. The condition rapidly grows worse, and the patient en- 
ters a state of stupor from which vigorous stimulation and the 
application of artificial heat fail to rouse her. These are the cases 
in which a differential diagnosis from haemorrhage cannot be 
made without a careful examination. If the abdomen be opened 
all the evidences of the most virulent form of septic infection are 
found in the abdominal wound and in the abdominal cavity. The 
patient dies because the heart and kidneys are overwhelmed by 
the intensity of the infection. The more usual form of post- 
operative infection of the peritoneal cavity comes on gradually 
on the second or third day, and is characterized by a progressive 
rise in the pulse-rate and temperature. The general symptoms 
presented will be in harmony with the degree of infection. Leu- 
cocytosis is usually marked. A blood examination fails to show 
Plasmodia. There is generally a small amount of albumen in the 
urine and a few granular and hyaline casts are found; tympanites 
is usually present, and abdominal pain from the first is marked. 
Vaginal examination will usually reveal the presence of lymph effu- 
sion about the uterus in cases where the adnexa had been operated 
upon. In no class of cases can more judgment be shown than in 
these late cases of post-operative sepsis. When the peritonitis is 
due to the colon bacillus and is characterized by the effusion of 
lymph, the operator is warranted in adopting a policy of delay; 
but when streptococci cause the peritonitis, a second operation 
is necessary, as a rule. The great difficulty is in identifying the 
exact degree of infection, and I can only advise the following 
plan of procedure: As soon as the temperature rises, and it is 
determined that it is not due to trauma but is surely of an in- 



MANAGEMENT OF PATIENTS AFTER CELIOTOMY 295 

fectious nature, the abdominal wound should be examined. At 
the same time the degree of tympanites, the location of any abdom- 
inal pain that may be present, the motility or rigidity of the ab- 
dominal parietes under the respiratory movements, and the pres- 
ence or absence of abdominal sensitiveness, are all noted. If the 
stethoscope is used, the presence or absence of intestinal peristalsis 
is determined, and if not found indicates peritoneal involvement. 
The blood should always be carefully examined, and before the 
administration of any drugs. A mild leucocytosis is invariably 
present after all capital operations, but rapidly subsides, and an 
increasing leucocytosis is indicative of sepsis and excludes reten- 
tion-toxicosis. The blood should always be examined for Plasmo- 
dia. There are no pathognomonic symptoms of any one of the 
conditions which produce fever after laparotomy, and I cannot 
lay down to the student the positive indications for performing 
a secondary operation. If I become convinced that the patient 
has septic peritonitis, it is my practice to open the posterior 
cul-de-sac, or, if this has been done before, to remove the dressings 
so as to examine the pelvic peritonaeum. If we find pus present 
in the peritoneal cavity we must determine whether it is simply 
an increase of what existed before the operation or is due to 
a secondary purulent peritonitis. If the first state exists the in- 
troduction of large iodoform dressings into the pelvis will fre- 
quently suffice; but if of the second type, gauze is introduced into 
the cul-de-sac opening and secondary laparotomy is performed, 
during which the appendix is carefully examined, and if necessary 
removed, the intestines drawn out of the wound, and all the 
recesses about the mesentery thoroughly washed with normal salt 
solution, the pelvis is sponged dry, and an abdominal Mikulicz 
drain of iodoform gauze is inserted and the wound closed around 
it. In such a case the operator employs through-and-through 
drainage, part of which projects from the abdominal wound and 
part into the vagina. The general treatment of post-operative 
sepsis is of the utmost importance whether a secondary operation 
be performed or not. Inasmuch as one of the causes of death 
from this condition is nephritis, the patient should be encouraged 
to drink large quantities of water, saline enemata of 8-ounce 
quantities should be given every four hours, and, if necessary, 
intravenous effusion employed. The prognosis will depend upon 
many factors, chief of which is the extent of the infection. Other 



296 GYNECOLOGY 

conditions being equal, the less the area of peritonaeum involved 
the better the prognosis. When the greater portion of the cavum 
magnum is the seat of infection there is but little hope for the 
patient. When general septic peritonitis exists recovery is im- 
possible. By general peritonitis is meant a degree of infection 
which involves the lesser as well as the greater peritoneal pouch. 
Contrary to the usual practice of surgeons, I am opposed to the 
administration of large doses of strychnine in this condition. Sep- 
sis produces contraction of the arterioles not only of the surface 
but of the viscera. I give small doses of strychnine and frequent 
small doses of nitroglycerin. The administration of nitroglyc- 
erin in these cases relaxes the peripheral vessels, thereby allowing 
fresh blood to the poisoned heart muscle and at the same time 
promoting kidney activity. I also administer brandy in 4 parts 
of water very frequently, giving the patient as much as -§ an ounce 
every two hours. Opium is absolutely contra-indicated except to 
ease the pangs of impending death. 

Ileus. — This term is used to designate a paralysis of a greater 
or less length of the small intestine due to adhesions forming 
after operation. It is seen to follow both laparotomy and vaginal 
hysterectomy, but is more frequent after the former. A knuckle 
of small intestine either forms a volvulus or becomes strangulated 
over a false band or, as stated, becomes adherent. When either 
happens the peristalsis of a large loop of the gut is interfered with, 
retention of its contents takes place, and these putrefy, causing 
gaseous distention of the involved loop. As distention increases 
the paralysis of the bowel increases. When complete stasis occurs 
reversed peristalsis in the bowel above follows. The condition 
probably begins shortly after the operation, but the symptoms 
supervene slowly. 

There is generally a colicky pain radiating about the umbilicus. 
This is so severe as often to produce slight shock. 

It will also be observed that little or no faeces have been passed, 
or that only the colon has been emptied. Vomiting soon sets in. 
Liquids and food may be retained for hours, and then the entire 
contents of the stomach be suddenly ejected. The abdomen rap- 
idly swells and becomes uniformly sensitive. As the case pro- 
gresses the matter vomited will be bile-stained, then stercoraceous. 
Faulty preliminary preparation of the patient, combined with post- 
operative administration of morphine, conduces to ileus. If mor- 



MANAGEMENT OF PATIENTS AETEE CCELIOTOMY 297 

phine has not been given, thus masking the symptoms, the oc- 
currence of stercoraceous vomiting is pathognomonic of intes- 
tinal paralysis either due to adhesions, strangulation, or volvulus. 
The patient, unable to retain fluids and nourishment, rapidly 
loses ground, her face becomes ghastly, a cold, clammy sweat 
bathes the body, the pulse gets weaker, and death ensues either 
as the result of starvation, or gangrene of the gut, or septic 
peritonitis. 

Ileus is diagnosticated with difficulty in its beginning, and is 
confused with sepsis, which it much resembles. In ileus the prog- 
ress is slower than in sepsis, the temperature does not rise so 
rapidly nor the pulse quicken to the extent seen in sepsis. There 
is at first little or no leucocytosis in ileus, while this is marked 
in sepsis. In ileus vomiting is an early and prominent symptom; 
not so in the beginning of sepsis. Tympanites very soon sets in 
in ileus, later in sepsis. In sepsis the shock is marked within a 
few hours, but in ileus does not occur for some days. 

So soon as the diagnosis is made, and the sooner the better, the 
cause of the condition must be removed. This, as a rule, is the 
formation of a broad band of union between a knuckle of the 
small intestine and the pelvis. If a vaginal section has been per- 
formed, the involved bowel is readily released under a few whiffs 
of chloroform, but if the lesion follows laparotomy the wound 
must be opened and the gut released. On no account should the 
surgeon try to force a stool by giving drastic purges. If the first 
few doses of saline cathartic are rejected, further through-and- 
through purgation is not to be attempted, the lower bowel merely 
being kept empty by an occasional high enema. Certain cases will 
get well without operative interference, and these are the ones in 
which the band of union is slight. But it is impossible to deter- 
mine exactly what cases will survive without operation. My own 
practice is to wait for reversed peristalsis accompanied by the 
vomiting of stercoraceous matter. Before this occurs the stomach 
should be kept absolutely empty and the necessary nourishment 
and liquids given by the rectum. At the same time the patient 
should be given moderate doses of strychnine hypodermically to 
improve the tone of the intestinal walls. I have thus sustained 
a patient for eleven days without a particle of water or food being 
taken by the mouth, and found that the symptoms gradually sub- 
sided. 



298 GYNAECOLOGY 

After operating for ileus the bowels should be allowed to rest 
for several days and the normal peristalsis gradually return rather 
than excite them by purgatives. 

An accident which has frequently occurred is opening of the 
wound and escape of the intestines from the abdominal cavity 
some days after laparotomy. Usually this is due to too early ab- 
sorption of animal suture material, but cases are recorded where 
the entire line of silk sutures has pulled through upon one side. 
The accident occurs under the strain of prolonged vomiting. The 
patient at once complains of a severe pain in her abdomen and 
enters a state of profound shock. Upon examining the wound 
the coils of small intestine will be found lying outside the abdom- 
inal cavity about the edges of the incision. They should be cov- 
ered with sterile dressings and the patient stimulated while the 
surgeons and assistants cleanse their hands. The patient is placed 
upon the operating-table and given chloroform. A careful in- 
spection of the intestines and incision is then made. If there 
has been no production of pus about the wound the coils should 
be washed in warm saline solution and returned to the abdominal 
cavity, which is then filled with the same solution. Any shreds 
of tissue about the wound are to be trimmed away and the wound 
closed by kangaroo sutures applied in tiers. The strain upon 
these can be taken off by long sutures of No. 26 silver wire, which 
pass through all the parietal layers and appear an inch or more 
outside the incision. These are not twisted, but their ends are 
secured by split shot. But if there has been inevitable infection 
of the coils of intestine these should be washed and returned as 
before. Over them several pieces of mild iodoform gauze are 
inserted to act as drains, and around these the wound is closed 
in tiers, the external sutures being of silver wire. The iodoform 
gauze is arranged so as to spread out in a fan shape between the 
intestines and parietal peritonaeum, the ends of the strips pro- 
jecting above the incision and between the sutures. Necessarily 
the mortality from this accident is very high. It can be avoided 
by the use of silver wire as a suture material for the outer tier 
of sutures. 

Suppression of Urine. — Suppression of urine occurs primarily 
from shock, and later on as the result of nephritis. The first 
form interests us here. The operator is informed that within a 
few hours after the operation the kidneys have nearly or quite 



MANAGEMENT OF PATIENTS AFTER CELIOTOMY 299 

ceased to act. Urinalysis before the operation enables him to 
eliminate nephritis, and he knows the ureters have not been tied. 
The condition is due to shock to the vaso-motor nerve system, 
which produces spasm in the renal vessels. It is at once relieved 
by a hypodermic of morphine, grain J, nitroglycerin, grain -^V? 
and a hot flaxseed poultice over the loins. 

Nephritis. — Nephritis is one of the most disagreeable compli- 
cations which can occur because so difficult to overcome. The 
author has seen the greatest benefit from cups over the kidneys 
and hypodermic injections of nitroglycerin and tincture of digi- 
talis. The colon should be flushed out by repeated high enemata 
of hot saline solution (enteroclysis), and in pronounced cases 
slow intravenous infusion is indicated. The fluid should be run 
into the vein very slowly, and if ursemic coma be impending vene- 
section upon the opposite arm should be performed. 

Shock. — Shock is the group of symptoms which present them- 
selves after operation and which are due to haemorrhage or in- 
jury to the important nerve centres. The pulse is small and rapid, 
the temperature subnormal, the surface of the body pale, and the 
skin bathed in cold perspiration. The patient after awakening 
lies apathetic, breathing shallow, face pinched, and all the senses 
blunted. The condition is to be corrected by the most vigorous 
treatment. If due to haemorrhage, intravenous infusion is indi- 
cated. If due to the prolonged exposure or rough handling of the 
abdominal viscera, nitroglycerin hypodermically, with -J grain of 
morphine and hot saline solution with 3 ounces of whisky thrown 
into the colon, will relieve the condition. 

Pleurisy. — The symptoms are the same as those laid down in 
the text-books on general medicine. I relieve the pain by the 
application of blistering plaster, and administer 3 grains of iodide 
of potash in abundance of water every two hours for 5 doses. 

Pneumonia. — This is generally due to the inhalation of septic 
germs during the narcosis. It used to be exceedingly frequent, 
but is much less so now owing to the care exercised in cleansing 
the ether cone. The symptoms are best described in the text- 
books on general medicine. It is nearly always a broncho-pneu- 
monia. 1 treat these cases by giving 5 grains of iodide of potash 
every hour for 3 doses in an abundance of water, omitting it for 
three hours, and then giving 5 grains every hour for three hours 
more. In twenty-four hours the routine administration of iodide 



300 GYNECOLOGY 

of potash, 3 grains 3 times a day, is begun and maintained as 
long as the sputum is tenacious. The general treatment is such as 
is usually employed in these cases. 

Tonsilitis. — The patient should be removed at least 6 feet 
from others in the ward, and be supplied with her own eating- 
utensils so as not to communicate the disease. The type of ton- 
silitis is usually the follicular, and due to the streptococcus. I 
treat this by giving a gargle of tincture of iodine 1 drop to 
each teaspoonful, and iodide of potash \ a grain to each tea- 
spoonful, the patient gargling about 1 teaspoonful of this every 
half hour and swallowing alternate doses, so as to reach the pos- 
terior portions of the tonsils. This is continued for about two 
days, and then the patient is put on a borolyptol gargle 1 part 
in 8 of water. 

Conjunctivitis. — This is usually due to the escape of ether into 
the eye, and frequently to the absurd habit of the narcotizer test- 
ing the reflexes by placing his dirty fingers on the conjunctiva. 
As soon as it is seen during the operation that ether has escaped 
into the eye, the lids should be held up and the eye thoroughly 
washed with saturated solution of boric acid. Upon returning 
the patient to bed iced cloths, frequently changed, should be laid 
upon the eye, and the eye should be washed out 4 times a day 
with saturated solution of boric acid. Preceding the washing a 
drop of weak solution of cocaine may be instilled. 

DRAINAGE AFTER CCELIOTOMY 

Drainage by means of a tube is little practised. It has been 
found impossible to keep the drainage track sterile, and as a result 
any ligatures adjacent to it, as well as contiguous structures, be- 
come infected. Besides the more remote result of drainage is the 
occurrence of hernia. Therefore, drainage through the abdominal 
wound is to be avoided if possible. The chief indications for 
drainage are found in those virulent forms of diffuse pelvic and 
abdominal infection clue to streptococci. In these the infecting 
agent not only produces intraperitoneal lesions, but also involves 
the retroperitoneal structures as well. It is in just such cases 
that intestinal lesions are found as complications. The drain is 
used not only to remove noxious products, but also to isolate and 
sterilize the involved field. The drain should therefore be of 



MANAGEMENT OF PATIENTS AFTEE CELIOTOMY 301 

5-per-cent iodoform gauze. The practice of surrounding this with 
rubber tissue defeats one great object of employing the dressing — 
namely, sterilization of the affected area by disintegration of the 
iodoform. The gauze is applied in stout rolls long enough to touch 
the bottom of the cavity to be drained and to project above the 
skin surface of the wound. Sufficient of the dressing should be 
applied to meet the purposes for which it is used. It is rarely 
necessary to change the dressing inside a week. In removing the 
soiled gauze the intestines are held back by narrow retractors, and 
while so maintained the fresh dressing is applied. A good deal 
of pain is produced in the change, but narcosis is not necessary. 
In former years this gauze drain, or Mikulicz dressing, was much 
employed, but now most of the cases formerly subjected to laparot- 
omy and drainage are successfully treated through the vagina. 
In five years the author has employed such abdominal drains but 
4 times, all of the cases being due to streptococcus and associated 
with appendicitis. As a general rule, it is better, where such a 
complication does not exist, to thoroughly cleanse the field of 
operation and drain through the vagina. To generalize, the ab- 
dominal drain of gauze is employed after operations in which the 
area to be drained lies above the pel- 
vic brim, while vaginal drainage is 
sufficient in cases in which the pelvis 
alone is involved. 

INTRAVENOUS INJECTION 
OF NORMAL SALT SOLU- 
TION 

A seven-tenths-of-one-per-cent so- 
lution of chemically pure sodium 

, , . . „. . . , „,, . Fig. 126.— Apparatus for Ixtra- 

chlorate m soft water is made. This VElfOTJa AND subcutaneous In- 
is filtered into either a Florence fusion. 

flask — to be found in all drug-stores 

— or else into a perfectly clean agate kettle. It is then boiled ten 
minutes and is cooled by placing on ice. The solution is emplo} T ed 
at a temperature of 110° F. The infusion apparatus is composed 
of a 12-ounce glass funnel, 8 feet of pure gum rubber tubing to fit 
this, and a cannula (Fig. 126). The apparatus is sterilized by boil- 
ing twenty minutes in plain water. The hand grasps the arm above 




302 



GYNECOLOGY 



the elbow and compresses the veins. The median basilic vein will 
show running across- the bend of the elbow from without in (Fig. 
127). The skin is drawn upward, and is incised carefully along- 
side the upper border of the vein. Upon rolling the skin down 

into position the cut is found to be over 
the vein. The vein is carefully dis- 
sected out of its bed. The distal or 
outer end of the vein is grasped across 
with an artery forceps, and -J inch in- 
ternal to this the vein is caught with 
mouse-toothed forceps. While this is 
being done, an assistant whose hands 
are absolutely clean has filled the in- 
fusion funnel. This he holds 6 feet 
above the patient. The clothing in the 
patient's axilla has been loosened. The 
operator severs the vein entirely across 
and takes the cannula in his right hand, 
while holding the bleeding end of the 
vein with toothed forceps. The saline 
solution is allowed to flow against the 
cut end of the vein until the solution 
feels warm ; then the cannula is inserted 
well into the vessel. At the same time 
the pressure on the arm is loosed. The 
assistant watches the flow of water from 
the funnel, and warns the operator 
when he is to refill it, so that the opera- 
tor may compress the tube and prevent 
entrance of air. To avoid this, all the 
water is not allowed to flow from the 
funnel before refilling. The speed of 
flow is about 6 ounces in three minutes, 
or about a quart in a quarter of an 
hour. The weaker the heart's ac- 
tion THE SLOWER THE CURRENT OF FLUID INTRODUCED, and as the 

arterial tension increases the speed of the infused fluid may be in- 
creased. After the operator has introduced the desired amount of 
fluid, the cannula is withdrawn and pressure made around the arm. 
It will be noted that as the patient reacts the cheeks flush and the 




Fig. 127. — The Anatomy at 
the Bend of the Elbow 

(Quain). 

a, «', a", internal cutaneous 
nerve ; 6, b', external cuta- 
neous nerve; i, the brachial 
artery and its vena? comites 
(#), seen through an opening 
which has been made in the 
deep fascia of the arm, and 
which is never opened in in- 
fusion ; 3, basilic vein; S'\ 3', 
ulnar veins ; 4-> cephalic vein ; 
4', radial vein ; 5, 5, median 
vein; 6, median-basilic vein, 
into which the infusion is 
made. 



MANAGEMENT OF PATIENTS AFTEE CGELIOTOMY 303 

skin becomes bathed in perspiration. After sufficient fluid has been 
introduced the two ends of the vein are secured by fine catgut, and 
the wound stitched by the same material. The quantity employed 
will vary with the necessities of the case from 1 to 3 quarts, the 
larger quantity being required in cases of haemorrhage and sepsis. 
The operation may be done under cocaine. Iodoform-gauze dress- 
ing is used. 

The author has observed the following immediate effect of 
intravenous infusion : the temperature rapidly falls if it has been 
high, and the pulse has been seen to come from 160 to 110 even 
during the operation. In other words, it is a positive remedy for 
shock. Remotely, the amount of urine is greatly increased, the 
specific gravity falls, owing to the dilution, but the actual amount 
of urea excreted is increased, and albumen, if present, is either 
markedly diminished or disappears altogether. The procedure is 
thus particularly applicable to cases of septicaemia and haemor- 
rhage. After operation it is demanded whenever the kidneys ex- 
hibit evidences of marked nephritis. 

Subcutaneous Injection. — Hypodermoclysis. — The material is 
prepared as before. Opposite the angle of the scapula and over the 
margin of the latissinms dorsi muscle the skin is cleansed. A few 
drops of cocaine solution are injected, or the skin is frozen with a 
stick of ice dipped in salt. It is incised for \ of an inch. While 
the edges are held apart the solution is allowed to flow through the 
cannula until warm, and the cannula is plunged into the cellular 
tissue between the skin and muscle. Ten ounces of fluid are 
allowed to enter, when the cannula is withdrawn and a stitch of 
catgut used to unite the surfaces. Iodoform-gauze dressing is used. 
Upon the other side a similar injection is made. As the fluid en- 
ters the cellular tissue a large swelling appears which subsides in a 
few minutes. The injection may be repeated lower down in eight 
hours. I have made 3 such injections in twenty-four hours in a 
desperate case of sepsis — altogether 60 ounces. If the fluid is 
sterile and careful cleansing of the skin and apparatus has been 
made there is little danger of suppuration following. In septicae- 
mic cases, however, suppuration often occurs at the point of hypo- 
dermoclysis. As the conditions for which infusion is performed are 
accompanied by contraction of the arterioles and capillaries, fluid 
beneath the skin is taken up but slowly. Therefore, intravenous 
infusion is more rapid and positive than subcutaneous injection. 



CHAPTEE XVII 
HYSTERECTOMY FOR PELVIC SUPPURATION 

Abdominal Panhysterectomy, Abdominal Ablation, Etc. — I 

have stated my belief that whenever both sets of adnexa are 
found involved their removal alone will not cnre the patient, 
for the uterus will be left in a distinctly pathological condition 
and may give much trouble subsequently. But if the patient is 
young and even one ovary be normal, the uterus may be left with 
the sound ovary. In such a case the extraneous circumstance of 
youth modifies the surgical indications. But as a general propo- 
sition, THE REMOVAL OF THE UTERUS IS INDICATED WHENEVER 
BOTH TUBES AND OVARIES ARE TO BE SACRIFICED. It is easier to 

remove the uterus completely with its adnexa than to dig these 
out and properly treat their stumps. Furthermore, the vascular 
supply is more readily controlled if the uterus is removed. Final- 
ly, so extensive are the adhesions in bilateral adnexal disease that 
drainage is often indicated. If the uterus is removed the drainage 
is through the vagina. The operation is particularly indicated 
in streptococcus infection where the subperitoneal structure, as 
well as the uterus and adnexa, is involved. In such cases drain- 
age is necessary, and is preferably downward through the vagina. 
The Operation. — The abdomen is to be entered in the median 
line. All the intestinal coils and the omentum should be liber- 
ated from adhesions within the pelvis and gently moved to a posi- 
tion above the pelvic brim, where they should be kept by large 
isolating gauze pads. The attached fimbriated ends of both tubes 
are then freed and the tubes and ovaries brought up into the 
incision for inspection. It is highly important to expose the tops" 
of the broad ligaments outside the tubes so that the ovarian ves- 
sels may be properly secured. These vessels are tied with medium 
tendon, and provisional ligatures of heavy silk are thrown around 
the uterine ends of the tubes so as to embrace the round ligaments, 
304 



HYSTEEECTOMY FOR PELVIC SUPPURATION 305 

tubes, and ovarian arteries alongside the uterus. The round liga- 
ments are now tied at the pelvic brim. The stumps of the ovarian 
arteries at the pelvic brim are then severed, and this cut is carried 
downward through the round ligaments and some distance into the 
broad ligaments and towards the cervix. The uterus can now be 
lifted up higher, dragging with it the deeper structures about the 
cervix. Across the anterior face of the uterus, where the bladder 
joins it, an incision is made through the peritonaeum, the ends of 
which terminate at the two cuts in the broad ligaments already 
made. The uterus should now be held upward as far as possible 
while the operator peels the bladder off the anterior face of the 
cervix and vagina. This manoeuvre will be easily accomplished by 
using a gauze sponge to rub down the bladder tissues. When the 
operator can feel the cervix through the anterior vaginal walls he 
cuts into the vagina, and carries this section of the vagina later- 
ally to the full diameter of the cervix. He next opens the pos- 
terior cul-de-sac by cutting down from above against his finger, 
which he has passed behind the cervix in the vagina. A stout 
hysterectomy forceps is applied upon each side close to the cer- 
vix, grasping all the tissues between the first cuts in the broad 
ligaments and the anterior and posterior incisions in the vagina. 
The points of the forceps are in the vagina. The uterus is now 
cut away. The forceps will now be seen to hold the cut ends of 
the uterine arteries. These, as well as any anastomotic trunks, 
are separately caught in artery forceps, and the hysterectomy for- 
ceps are removed. Each vessel is now tied. The pelvis is wiped 
dry and the vagina packed lightly with strips of iodoform gauze, 
the ends of which project just above the cut edges of the vagina. 
If the folds of the broad ligaments spread apart the two layers 
of each may be approximated by several sutures. The vault of the 
vagina is not closed over. The pelvis is wiped dry, and upon 
releasing the rectum from retaining pads it will be found to fall 
forward against the bladder, completely covering the gauze in the 
vagina. The omentum is pulled down and the abdomen closed 
without drainage. The vaginal drain is left in place for a week, 
and is then removed and renewed. The after-treatment of the 
vaginal wound is the same as though vaginal hysterectomy had 
been done. 

The above is the usual and typical operation, but in rare in- 
stances the complications may be such as to compel a departure 



306 GYNECOLOGY 

from this. In certain cases the bilateral fixity of the organs and 
the' density of the adhesions to important organs, as the rectum 
and ureters, will lead the operator to seek greater mobility by 
employing the procedure of hemisection of the uterus, which is 
such an aid in vaginal hysterectomy. He inserts one finger down 
to the bottom of Douglas's cul-de-sac, freeing the adnexa from the 
uterus only that far. Then, while holding the uterus upward, he 
incises the peritonaeum at the vesico-uterine fold, and separates 
the bladder from the uterus. Each cornu of the uterus is now 
grasped by serrated traction forceps and handed to assistants. 
The operator then splits the uterus in two, more traction forceps 
pulling up and outward the two sides as his incision is carried 
downward. This cut proceeds along the median line and com- 
pletely splits the uterus, entering the vagina below. One half of 
the cervix is now grasped and lifted up while the operator cuts 
it away from the vagina. After he has done this he still further 
lifts the cervix until he feels the pulsation of the uterine artery, 
or by blunt dissection has exposed it. This he grasps with forceps, 
and then cuts the cervix loose from the base of the broad liga- 
ment. The cervix can now be so far lifted that the arterial anas- 
tomosis alongside the uterus can be caught and tied. The operator 
can now dissect this half of the uterus and its adnexa away from 
all attachments, and without difficulty. When the ovarian vessels 
are reached during this upward dissection of the adnexa they are 
tied, and this half of the uterus, the ovary, and tube are removed. 
The same procedure is carried out on the other side. The vessels 
are secured by ligatures, the vagina packed with gauze, and the 
case otherwise treated as in the typical operation. 

Vaginal Hysterectomy, Vaginal Ablation. — The Incisions. — 
Having become convinced, after making the exploratory vaginal 
incisions, that an ablation is necessary, the operator proceeds to 
spread the posterior vaginal incision from side to side. After 
doing this he introduces a gauze pad into the opening to catch 
fluids. The anterior incision is next made. To do this I intro- 
duce into the uterus my intra-uterine traction forceps, and spread 
it until a firm grasp is secured upon the organ. 

The cervico-vesical fold is accurately determined by pushing 
the uterus up until the point of reflection of the vagina from the 
cervix is seen, and, cutting against the cervix, the latter is circled 
to within •§• of an inch of the posterior cut (Fig. 105). Thus a 



HYSTEEECTOMY FOR PELVIC SUPPURATION 307 

narrow strip of vaginal skin is left upon each side. I do not 
make this anterior incision near the external os, because I wish 
to cut above the very dense tissues about the external os and yet 
leave abundance of vagina. If the dissection is made near the os, 
bilateral space is secured with difficulty, for the incision will be 
surrounded by a ring of inelastic tissue. In other words, the an- 
terior incision should be made in vaginal tissue and not in cer- 
vical. So soon as the scissors has cut through the vaginal skin, 
it is closed and laid sideways upon its edge in the cut. Bearing 
down hard upon the cervix, the operator shoves the tissues up for a 
short distance, or until the looser tissues are reached. The closed 
scissors used in this way acts as does a periosteum elevator. After 
the dissection has proceeded upon the anterior face of the cervix 
for about ^ an inch, a short retractor is inserted into the wound 
and the bladder held up. Upon wiping the wound dry a few bands 
of connective tissue and muscular fibre may be noticed extending 
from the sides of the incision towards the centre and angle of 
the denudation. These are snipped with the scissors. After this 
all attempts to enter the anterior peritoneal pouch are made with 
one finger. Holding the uterus firmly with the intra-uterine trac- 
tion, the operator pushes the vesico-uterine tissues up. He does 
this by bearing hard down upon the uterus with the index finger 
and literally rubs the bladder tissues from the uterus. This 
is done not with the nail but with the palmar surface of the 
finger. It is in this bladder dissection that the great value of the 
intra-uterine. forceps is seen. With it the uterus can be rotated 
so as to differentiate the loose pericervical tissues from the uter- 
ine ; and in stripping the bladder from the uterus it furnishes a 
most admirable point of counter-pressure. It gives the operator 
a fixed body to work against and not a movable one. I have 
rarely found it necessary to sever the peritonaeum with instru- 
ments. The finger, whenever it can reach the fundus anteriorly, 
will easily penetrate; and in cases where the peritonaeum is at- 
tached high on the uterus, it should not be blindly opened until 
the uterus can be pulled down after hemisection. 

After entering the anterior peritoneal pouch and making the 
dissection as high as the finger will reach, I separate the bladder 
from the uterus to the sides. The anatomical fact must here be 
noted that the width of the bladder is greater than that of the 
uterus, and that the organ extends laterally upon the broad liga- 



308 GYNAECOLOGY 

ments. The operator sticks to the middle line in entering the 
anterior peritoneal pouch, and makes the lateral separation by 
moving the finger, laid flat upon the uterus, from side to side. 
The uterine vessels at the sides can be felt pulsating, and the 
dissection should not be carried beyond their level. If the operator 
is rough he can easily rupture the uterine vessels. So far there 
has beeen but little bleeding. The azygos artery on the posterior 
vaginal wall has been severed in opening the cul-de-sac, and tem- 
porarily clamped if prominent. The small vessels from the uterine 
arteries which enter the cervix give some trouble if wounded. 
They anastomose freely with the vesical arteries. I do not pay 
attention to them until I am ready to clamp the uterines. The 
operation has progressed to the point where the uterus is free from 
its attachments to the bladder and posterior vaginal wall. I have 
termed this the first stage, for it is done in all cases, be the further 
manoeuvres what they may. 

In making these incisions and separating the bladder, what 
is the position of the ureters? At the point Avhere the uterine 
artery springs from the internal iliac, the ureter lies at least 
\ of an inch below the artery. As the artery abruptly crosses 
the pelvis to the side of the uterus it passes across the ureter. 
This point of crossing is always at least 1 inch from the nor- 
mal cervix, and is where the broad ligament spreads out for its 
attachment to the side of the pelvis. After this the ureter and 
uterine artery are never in relation. The ureter sweeps in a grace- 
ful curve to the bladder and is in front of the uterine artery. 
The uterine artery does not curl around the ureter, as usually 
pictured. From the time the ureter crosses the pelvic brim it 
begins to sink below the internal iliac artery, and when the uter- 
ine artery is reached, the ureter is easily \ of an inch below the 
uterine. The ureter proceeds anteriorly to the bladder, while the 
uterine artery crosses the pelvis to the cervix (Fig. 128). Upon 
separating the bladder from the uterus and lifting it up, the 
ureters are swung outward and farther upward; and pulling the 
uterus down and towards the sacrum, while lifting the bladder still 
further moves the uterine artery to a deeper and more posterior 
position. When the bladder is separated and held up and the 
uterus pulled down, the ureters and uterine arteries are farther 
apart than they were before the operation. But if the bladder 
is not separated and lifted, down-traction upon the uterus de- 



HYSTERECTOMY FOR PELVIC SUPPURATION 309 

creases the angle of divergence between the artery and ureter, and 
they may be made to touch for the inner half of the artery and 
up to \ -an inch of the cervix. Repeated dissections by me have 




Fig. 128. — A Section of the Pelvis has beex made so as to pass through the 
Uterus. (Tandler and Halban.) 
The body of the uterus has been cut away to show the bladder, Ve., held up by the 
trowel ; Po., cervix ; _F., ischio-reetal fat ; U., ureter, which is also shown yellow 
lower down ; V. Va. IF., vaginal ruga? ; & Va., anterior vaginal wall. 



Wa.W 



shown this. The ureters cannot be wounded by any force applied 
at the sides of the uterus, provided such force does not tend to 
draw the cervix and bladder together, as, for instance, an im- 
properly applied ligature does. 

I leave a narrow strip of vaginal mucous membrane upon each 



310 



GYNAECOLOGY 



side and between my anterior and posterior incisions for two 
reasons : Before I apply the forceps to the uterine vessels this strip 
of tissue prevents tearing off the forceps during future manipula- 
tions. Furthermore, I have thought this prevented to some extent 
sagging down of the vagina after completion of the process of 
healing, inasmuch as the vaginal vault and the bases of the broad 
ligaments are then one. 

In certain cases the bladder is attached so high up on the an- 
terior surface of the uterus that the operator cannot reach the 
anterior peritonaeum with his finger. He should then make his 
dissection as high as he can, and withdraw the intra-uterine trac- 




Fig. 129. — Hemisection of the Uterus. 
The cervix is shown split open. 



tion forceps. In order to enter the peritonaeum it is necessary 
for him to pull down the anterior surface of the uterus. To do 
this he grasps each side of the cervix with bullet forceps and splits 
the anterior lip of the cervix in the middle line to a little above 



HYSTERECTOMY FOR PELVIC SUPPURATION 311 

the level of the internal os (Fig. 127). Upon rotating the bullet 
forceps outward the cervical canal will flare out, and a por- 
tion of the anterior uterine wall will come down. This is cut 
with scissors in the middle line. While making this anterior 
median section of the uterus, the bladder should be held up by 
a narrow retractor, and as each successive portion of the anterior 
wall of the uterus comes into view, it is grasped by traction for- 
ceps. After a time, at the upper angle of his incision, the oper- 




Fig. 130. — Hemisection of the Uterus. 

The anterior face of the uterus has been split. The grooved director is in place, and the 
knife is shown ready to complete the hemisection. 



ator will see the smooth peritoneal covering of the uterus. He 
has, perhaps unconsciously, entered the anterior peritoneal pouch 
by holding up the bladder and progressively splitting the anterior 
face of the uterus. 

Hemisection. — However, as a rule, the operator will experience 
little difficulty in entering the anterior peritoneal pouch before 
20 



;i2 



GYNAECOLOGY 



splitting the uterus. This section of the anterior face of the uterus 
proceeds along the median line. The cervix is first split and then a 
portion of the body of the uterus and the upper borders of the cut 
are seized by the toothed traction forceps. As these are drawn 
upon and rotated outward, it will be found that more of the 
uterine body comes into view and is unfolded, so that the uterine 







Fig. 131. — The Eight Half of the Uterus has been shoved up into the Pelvis 

while the Left Half is drawn down. 
All retractors are withdrawn, and the operator shoves his hand into the pelvis to free 

adhesions. 



cavity is flattened out. All of the uterine cavity that can be seen 
is split in the middle line, and other traction forceps entered 
higher up. In this way the fundus is reached and severed. All 
specula are now withdrawn, and the grooved director is intro- 
duced behind the uterus, entering behind the cervix. A finger is 
inserted beneath the bladder and the director is felt; and again 
the finger is forced behind the uterus to see that no intestines 



HYSTERECTOMY FOE PELVIC SUPPURATION 313 

lie between the director and the uterus. The assistant is told to 
press down the perineum hard with the director, while the curved 
portion of the instrument pulls forward the uterus. A short specu- 




Fig. 132. — Note how the Hand doubles the Eight Half of the Uterus while 
the Thumb holds the Eight Adnexa forward. 

The top of the right broad ligament is shown passing between the index and middle 
fingers. The forceps is being applied to the right ovarian artery. 



lum is inserted behind the bladder until the groove in the director 
is seen. Into this a special bistoury is inserted, and the uterus is 
split accurately in two halves. This completes the second stage. 



314 GYNAECOLOGY 

The director is drawn out. The right (on operator's left) 
adnexa and right half of uterus are shoved into the pelvis, while 
traction is made upon the left half of the uterus. Had I not left 
a narrow strip of vaginal mucosa upon each side when I shoved 
up this half of the uterus, the uterine artery might be torn from 
its bed and its branches to the cervix broken. After the left half 
of the uterus has been turned out from beneath the bladder, it is 
swung to the patient's left, and all of the operator's left hand 
except the thumb is inserted into the pelvis. The left adnexa 
are readily liberated from all adhesions behind the broad liga- 
ment, as the operator can reach the pelvic brim. The operator then 
allows the left half of the uterus and the free adnexa to escape 
into the pelvis, and draws down the right half of the uterus, and 
liberates the right adnexa. The right adnexa are now held in 
front of the uterus, and the first forceps is applied to the top of 
the broad ligament outside the ovary. This forceps grasps the 
round ligament as well as the ovarian artery as it courses through 
the broad ligament. The tissues between the forceps and uterus 
are cut with scissors nearly down to the points of the forceps, and 
a forceps is applied from above downward so as to firmly grasp 
all the tissues to the side of the cervix, including the uterine ar- 
tery and narrow strip of vaginal skin which was left between the 
incisions around the cervix. This second forceps is applied in- 
ternal to the first and close to the cervix. This half of the uterus 
is now cut away. These forceps are allowed to hang loosely, and 
the left half of the uterus, with its appendages, is drawn out of 
the vulva. Two forceps are applied upon the left side as others were 
upon the right, and the remaining half of the uterus is removed. 

The relation of the ureter to the cervix is greatly modified 
by the hemisection. In applying the forceps to the uterine artery, 
the cervix is drawn sharply to the opposite side. This straightens 
the curved portion of the uterine artery, and markedly increases 
the distance between the cervix and the point at which the uterine 
artery is in relation with the ureter. It will be noticed that no 
retractors are employed during this stage. They are only in the 
operator's way. After the uterus and adnexa have been removed, 
gauze pads, each secured by a stout string, are introduced into 
the pelvis above the forceps. The perinaeum is drawn down by 
a long Jackson retractor, while the bladder is held up by a 
trowel. The table is lowered, and a careful inspection is made of 



HYSTERECTOMY FOR PELVIC SUPPURATION 315 



the stumps and pelvic contents. If bleeding points are seen they 
are grasped ; but if the operator has done his work properly, four 
forceps are all that will be needed. The gauze pads are removed, 
and the pelvis is carefully cleansed by gauze swabs, particular atten- 
tion being paid to the cul-de-sac. This completes the third stage. 

A piece of iodoform gauze is inserted between the forceps and 
the vagina upon each side. Each set of forceps is then drawn 
towards the lateral 
pelvic wall by means 
of a long, narrow 
retractor. Between 
them enough strips 
of gauze are inserted 
to fill the space. 
These strips project 
up above the points 
of the forceps. The 
patient is lowered to 
the horizontal posi- 
tion, and a self-re- 
taining catheter is in- 
troduced on a sound. 
The sphincter ani is 
dilated thoroughly. 
This is done to al- 
low of the easy escape 
of intestinal gases 
and to allay spasm 
of the levator ani 
muscle. The oppos- 
ing muscle to the le- 
vator ani is the sphincter. Under the bruising and stretching to 
which the levator is subjected, it is apt to spasmodically contract 
if held down hard by the undilated sphincter. Patients who have 
the sphincter dilated are more comfortable than are those in whom 
this is not done. A piece of plain gauze is wrapped around the 
forceps and tied. The operation is completed. 

The method of making these dressings is radically different 
from that employed elsewhere. I consider it an essential feature 
of my method. The Mikulicz dressing is employed here to absorb 





r. 



Fig. 133.- 



Sh owing the Method of applying the 
Pelvic Mikulicz Dressing. 



316 



GYNAECOLOGY 



all discharges. It should be of sufficient volume to do this during 
the week in which plastic union is taking place between the rec- 
tum and bladder. But there is another reason why I pack these 
cases so snugly. It is to avoid an accident which not infrequently 
happens to those who use the gauze in slender strips only. When 

the latter dressing is 
used, at the time the 
forceps are removed, 
the sloughing ovarian 
stumps very often snap 
back into the pelvis, 
causing secondary in- 
fection. The pelvic 
Mikulicz dressing 
holds these stumps 
immovably fixed at 
the vaginal vault, and 
I have never seen such 
secondary infection. 

In a case of what 
I supposed was a sec- 
ondary haemorrhage 



/ 




Fig. 13-i. — The Completed Operation. 

The four forceps are shown surrounded and supported 
by the iodoform-gauze dressings. 



from an ovarian ves- 
sel, when I removed 
the forceps on the 
second day I made a 
rapid section of the belly. There was even at this early day found 
firm plastic union between the bladder and rectum, and the field of 
my vaginal operation was found completely shut out from com- 
munication with the general pelvic cavity. 

In certain cases it will be found that the uterus, even if di- 
vided, could not pass through the opening in the vault of the 
vagina, or it may be impossible to complete the hemisection, 
owing to the large size of the uterus, which fills the pelvic outlet 
so that the fundus cannot be reached. The uterus is then removed 
by morcellation. 

Morcellation. 1 — Eemembering that the blood-supply of the ute- 



1 In reading this article the one on "vaginal removal of nbro-myoma uteri 
may be consulted. 



HYSTERECTOMY FOR PELVIC SUPPURATION 317 

rus approaches the cervical and cornnal points and has lateral 
anastomoses between the upper and lower vessels, and that the 
arteries which course across the anterior and posterior surfaces 
of the uterus are small, the operator feels secure in severing all 
tissues which lie between the lateral ovarian-uterine anastomoses. 
The object in doing this is to so weaken the tissue in view that 
more can be pulled down from above by the process of decen- 
tralization, or removing the centre, thus causing a diminution 
in the bilateral diameter of the organ. There are two chief ways 
of doing this. The one most successful in dealing with large 
uteri associated with pus (the condition we are discussing) is to 
weaken the anterior uterine wall by removing successive vertical 
strips of tissue. Mere fixation of the uterus is no indication for 
morcellation; the fixation must be accompanied by marked en- 
largement. Typical or symmetrical morcellation is rarely possible 
when dealing with pus cases, the operator often combining sev- 
eral methods in excavating the uterine wall. 

It is a great aid if the posterior cul-de-sac can be opened. 
This is first done; next the bladder is dissected from the uterus 
until the anterior peritoneal pouch is opened. While the bladder 
is held up by a Jackson speculum and the intestines protected 
by a gauze pad, the anterior wall of the uterus is split as high 
as possible. Holding the everted edges of the cut with bullet 
forceps, the operator trims a strip of tissue about \ of an inch 
wide, first from one side and then from the other. Half an inch 
has now been taken out of the entire visible anterior uterine wall. 
The removal of this amount of tissue from the cervix will usu- 
ally be all that can be taken away without reaching its sides. The 
other slices cut out will be above the cervix and from the body of 
the uterus. In most cases it will be found that the removal of the 
first two strips has so weakened the anterior uterine wall that the 
median splitting of the anterior wall can be continued, and the 
cornua uteri can be brought into view beneath the bladder. But 
in some cases the bladder is attached so high up upon the uterus 
that the dissecting finger cannot effect the separation. Then it 
will be necessary to split the uterus up as high as possible and 
remove from each side one, and perhaps two wedge-shaped pieces, 
with their bases upward. The stumps are firmly grasped and 
the anterior wall pulled farther down, while the bladder is pushed 
up so as to expose more of the uterine tissue. What appears is 



318 GYNECOLOGY 

again split in the middle line, and from each side a wedge of 
tissue is removed. Progressively pulling down the uterus and 
cutting out pieces, the cornua appear. So far there has been free 
capillary bleeding, but none from vessels of large size. Haemo- 
stasis has not yet been employed. When the cornua come into 
view, if necessary a large wedge is cut from the fundus, the base 
of which is at the top of the uterus. This piece will encroach upon 
the posterior surface of the uterus, and at once upon its removal 
the cornua with their tubes come still further into view. The 
grooved guide is now inserted behind the uterus and the organ 
split in two parts. The other steps of the operation are described 
under Hemisection. In reality, morcellation is not a very impor- 
tant factor in the removal of inflamed uteri. In fibroid extirpa- 
tion it is an invaluable essential. 

Complications and Accidents. — Appendicitis, with some oper- 
ators, constitutes a great objection to the vaginal method. But 
2 cases in 229 vaginal ablations required a secondary section 
for appendicitis while in my care. Many operators consider all 
adherent appendices diseased. I do not, any more than adherent 
knuckles of other parts of the gut. Perfectly normal appendices 
are often adherent to the diseased right adnexa. I have no diffi- 
culty in freeing them through the vagina. Intestinal adhesions 
are likewise loosened without damage to the walls of the gut. 

I have never wounded a ureter nor had one injured in con- 
valescence. Such accidents are not infrequent in laparotomy. 

I have wounded the bladder 3 times. In 1 case only was it 
necessary to secondarily suture the bladder, the other 2 closing 
spontaneously. I have found 5 faecal fistulas at the time of 
operating and 1 occurred after a patient went home, caused by 
her carelessness. Three closed without operation, 1 by operation, 
and 1 failed to close after operation, the patient being syphilitic. 
This is not a large proportion of fistulas, for in the first report 
of suprapubic operations made by me of 85 cases I found 5 fis- 
tulas. Interintestinal adhesions do not result from vaginal abla- 
tion, although frequently found to cause chronic constipation 
after laparotomy. Hernia through the vaginal scar is not seen, 
though hernia through the abdominal incision is found in at 
least 5 per cent of abdominal sections. Secondary haemorrhage 
has occurred 5 times. When it does occur it can usually be con- 
trolled by the vagina, though before I found this out I 3 times did 



HYSTERECTOMY FOE PELVIC SUPPURATION 319 

a secondary laparotomy, in a fibroid case once, in a pus case 
twice. Of these secondary operations 2 were unnecessary but 
taught me much regarding the distribution of the pelvic contents 
after vaginal ablation. 

Kelly found that 0.44 per cent of his laparotomies had sec- 
ondary haemorrhage requiring supplemental abdominal sections. 
I find that in my 229 cases of vaginal ablation I have had 3 
secondary haemorrhages requiring supplemental abdominal sec- 
tion, or 1-J- per cent. 

I have lost no case from post-operative pneumonia or from 
nephritis. Slight iodoform intoxication has occurred 4 times, but 
soon passed off without deleterious effects. I have had no case 
of sudden death due to cerebral lesions. With two exceptions the 
convalescence of the cases has been smooth, and I have seen no 
evidence of that " late infection " which gives the European sur- 
geons a considerable mortality. I have lost 1 case in 229 opera- 
tions — a mortality of 0.4 per cent. 

Segond has reported several cases of acute decubitus, but so 
far I have not encountered it. Mild phlebitis has occurred 3 times 
only, a small percentage when we consider the gravity of many 
of the cases and the frequency of this complication after abdom- 
inal hysterectomy. Once I operated late after a puerperal infec- 
tion, in which a left broad-ligament abscess had formed, and I 
was compelled to open a secondary abscess above Poupart's liga- 
ment. Not the least attractive feature of this operation is its 
simplicity and the rapidity with which it can be performed under 
an incomplete narcosis. It is not necessary to secure that absolute 
muscular relaxation which is an essential of laparotomy. 

RELATIVE MERITS OF ABDOMINAL AND VAGINAL 
HYSTERECTOMY IN PUS CASES 

In view of the confusion which exists in the minds of most stu- 
dents of gynaecology regarding the relative merits of vaginal and ab- 
dominal ablation and pelvic inflammations, I deem it advisable to 
state my reasons in preferring in most cases the former, and to indi- 
cate in what class of cases the abdominal operation is to be selected. 

The incision in the vaginal operation severs two anatomical 
layers only, whereas in the abdominal operation the skin, fat, 
fascia, muscle, and peritonaeum are cut. Rarely in vaginal hys- 



320 GYNAECOLOGY 

terectomy is it necessary to apply ligatures to spouting arteries, 
while in laparotomy very frequently many ligatures are neces- 
sary to control the bleeding made by the incision. Both opera- 
tions necessitate separation of the uterus from the bladder; but 
in accomplishing this the advantage is markedly with the vaginal 
operation, because then the operator has the cervix as a guide, 
and has under perfect command that portion of the uterus to 
which the bladder is attached. In the vaginal operation the ute- 
rus is not masked by the viscera, which always lie in the way 
in laparotomy. It is not necessary to sever the perineum to en- 
large the vaginal outlet; but were I obliged to do so in removing 
the uterus, I should abandon the vaginal operation as carrying 
with it, under those circumstances, a traumatism equal to that 
accompanying laparotomy. 

In separating adhesions in laparotomy it is often necessary 
to work through a mass of matted intestines before the organs 
to be removed are seen, while in vaginal hysterectomy all the 
work proceeds below the abdominal complications which lie above 
the uterus. This is a most valuable attribute of the vaginal oper- 
ation, and may be somewhat further discussed. We have two 
kinds of adhesions to deal with : those between the abdominal 
viscera and those between the inflamed organs and the abdominal 
viscera. In vaginal hysterectomy the interintestinal adhesions 
are not interfered with. Some have stated that it is necessary 
to sever these in order to give the patient as good a result from 
the operation as possible, but it is my observation that even though 
the adherent knuckles of intestine are liberated, they can form 
a union more firm and more general than at first existed. But in 
freeing adherent knuckles of intestine in laparotomy, great tears 
are not infrequently made in the intestinal walls, which often 
require suture. Again, the manoeuvres employed to liberate ad- 
herent intestines rub off the endothelium, and in these pus cases 
such raw surfaces become infected, to form additional adhesions. 
Neither statement is applicable to the discussion of the vaginal 
operation. In this procedure the organs to be removed are read- 
ily freed from all attachments above, and the raw surfaces thus 
created remain turned down, where provision is made for drain- 
age, and are not dragged up, as in laparotomy, above the pelvic 
brim, to carry the infection to tissues not previously involved. 
Furthermore, in this operation all those complications which ex- 



HYSTERECTOMY FOR PELVIC SUPPURATION 321 

isted above the uterus are not disturbed as the operation proceeds 
beneath the matted mask of viscera which lies above the uterus. 
In laparotomy very often a tedious grave surgical operation is 
done before the organs to be removed are seen ; whereas in vaginal 
hysterectomy the diseased organs are most often removed without 
the operator seeing a single knuckle of small intestine. 

The direction of effort in laparotomy proceeds through an in- 
cision, which it is expected shall heal by first intention, and 
through a mass of adherent viscera. The infected organs are 
dragged up between the raw surfaces left after separating the 
adherent intestines and between the margins of the abdominal 
incision. The fingers, whether naked or gloved, repeatedly take 
the same path, and no hand which has been engaged in liberating 
and removing pus foci can be insured as clean. In laparotomy 
the organs removed are dragged from their pelvic attachments 
through the lower part of the abdomen. In vaginal ablation the 
direction of the effort is in the direction of drainage at the lowest 
part of the peritoneal pouch. The pelvic filth remains pelvic, 
and is never led into the abdomen. It does not pass by tissues 
which are to be sutured, and does not infect areas of intestine 
from which the endothelium has been removed by manipulation. 

Hcemostasis. — In laparotomy this is by means of ligatures 
which must be absorbed; certainly those upon the ovarian ves- 
sels are cut short and left in. These ligatures are so frequently 
infected, being placed in an infected field, that they are often 
sources of trouble although isolated in a mass of lymph. All the 
problems embraced in a consideration of the choice of ligature 
material, its preparation and its fate, are factors when the oper- 
ation is done through the abdomen. They are not considered 
in the vaginal operation. 

Drainage. — In laparotomy this must sometimes be employed, 
particularly in cases of streptococcus infection, diffuse suppura- 
tion, and where tubo-rectal fistulas exist. As a result, the isola- 
tion of the area drained is effected by a matted mass of lymph 
thrown out by the intestines, and a breach is left in the abdom- 
inal scar. Besides, the pelvic filth is drained through the normal 
abdominal cavity, and is up-hill. In vaginal ablation the drainage 
is always used. It is at the lowest part of the pelvic cavity. The 
intestines do not become adherent to the drain or area drained ; the 
pelvic filth remains pelvic, and drainage is down-hill. 



322 GYNAECOLOGY 

Drainage after laparotomy, though not often used nowadays, 
infects the entire area adjacent to the drain from the pelvic floor 
to the abdominal skin. Drainage after vaginal ablation passes for 
not over an inch through the lowest part of the pelvic peritonaeum, 
and most of it is through the vaginal tube, which is particularly 
adapted to carry off the material drained away without absorbing 
any. The infected drainage space after laparotomy remains for 
a large part an abdominal complication, and for weeks. 

After vaginal ablation the drainage track is in a few hours 
made extraperitoneal by the union of bladder to rectum. 

Sutures. — These are not used in vaginal ablation. So impor- 
tant a matter is the method by which the abdominal wound should 
be closed that there are about as many varieties as there are 
operators. Shall the wound be closed by buried catgut, buried 
kangaroo tendon, or buried silver wire? Shall the wound be 
united by suturing in tiers or through-and-through suturing, or 
shall the fat be left open? Shall the suture be applied as in- 
terrupted, or mattress, or continuous sutures? 

Hernia. — The percentage of hernias after laparotomy is not 
known, but there are many of them. They are not known to 
follow the vaginal ablation by forceps. The intra-abdominal ef- 
fort is almost wholly borne above the symphysis, while the vaginal 
vault is protected from this force by the posture of the body and 
the sacral promontory. 

Accidents. — In abdominal hysterectomy the bowel must some- 
times be sutured; the ureters have been cut; abdominal fistulas 
are known to exist, and ligatures have worked their way into the 
bladder. After vaginal ablation intestinal suture and resection 
must be exceedingly rare procedures. In the few cases in which 
the bladder has been wounded the rents closed without suture. 
Unless made by the veriest tyro, no wounded ureters are heard of 
and no abdominal fistulas are found. 

Narcosis and Time. — Abdominal hysterectomy necessitates an 
abdominal section and a hysterectomy. Vaginal ablation is a 
hysterectomy only without the abdominal section. Few men can 
perform a finished abdominal hysterectomy in less than three-quar- 
ters of an hour in pus cases. Twenty minutes only need be con- 
sumed in vaginal ablation. In order to secure relaxation of the 
abdominal muscles profound narcosis is necessary in laparotomy. 
With vaginal ablation the narcosis is incomplete and short. 



HYSTERECTOMY FOR PELVIC SUPPURATION 323 

Convalescence. — Any man who has seen a number of similar 
cases treated by the two methods will decide that the ability to 
turn over in two days, the assumption of regular diet in four 
days, the regularity of the bowels from the first, the absence of 
nausea and vomiting, the early getting up, make the convalescence 
from vaginal ablation much less disagreeable than from lapa- 
rotomy. 

The mortality from abdominal hysterectomy in pus cases is 
more nearly 3 per cent than under it, and the author's mortality 
from vaginal operation in similar cases is i of 1 per cent. 

VAGINAL HYSTERECTOMY IN COMPLETE 
PROLAPSE 

It was a matter of comment that after the total abdominal 
hysterectomy had been performed and the stumps turned down 
into the vagina, the vaginal scar remained held high in the pel- 
vis after healing was complete. This was due to a union between 
the broad ligaments and the vaginal scar. It was but a single step 
to employ this fact in the treatment of complete prolapse. The 
uterus and adnexa should be removed en masse between forceps, as 
described. After the ablation is completed each stump is transfixed 
by a pedicle needle armed with medium-sized chromic tendon and 
tied in two placed outside the forceps. Each forceps is removed 
as the first knot is tied, and then the second knot is rapidly made. 
If the knot is tied before the forceps is loosened, the pedicle will 
not be sufficiently constricted. After the four stumps are secured 
by ligatures, 2 sutures are passed upon each side through the an- 
terior and posterior walls of the vagina, and each is made to pass 
through a stump above its ligatures and as high up as the oper- 
ator can reach. In this way the vagina will be drawn up and 
the stumps down. These ligatures are then tied, and will close 
the vaginal incision except a small portion in the centre into 
which a gauze drain is to be inserted. The lymph which forms 
about this drain still further tends to hold the vagina up. The 
dressings and after-treatment are the same as in other vaginal 
hysterectomies. This operation is particularly indicated in elderly 
women, because it can be rapidly performed under a partial nar- 
cosis and does not keep the patient in bed over ten days. It is 
contra-indicated in women in the childbearing period of life. 



324 GYNECOLOGY 

SECONDARY HEMORRHAGE AFTER VAGINAL 
HYSTERECTOMY 

Whenever large vessels in the body are secured, either in con- 
tinuity of tissue or en masse, this accident may follow, and the 
vaginal operation is no exception to this rule. The vessels may 
be perfectly secure under the forceps, and yet secondary bleeding 
occur any hour between the time they are removed and two weeks 
later. The bleeding usually springs from one uterine artery, and 
is readily controlled by bilateral pressure. The patient should 
be taken to the operating room and placed in the lithotomy pos- 
ture, her buttocks close to the table's edge and knees drawn up 
over the abdomen. A narrow retractor is introduced through the 
centre of the column of gauze, and one half of the gauze — that 
upon the side from which the bleeding comes — pulled hard 
against the lateral pelvic wall. A similar retractor is entered 
alongside the first, and the other half of the gauze pulled to one 
side. When it is seen that the pressure is sufficient to stop the 
bleeding, the vaginal packing is increased by the introduction of 
additional pieces of gauze between the two retractors. The re- 
tractor which holds back the gauze over the bleeding vessel is not 
to be moved until the dressing is complete, but the adjustment 
and compression of all fresh pieces of gauze are effected by means 
of the opposite blade. After waiting a few minutes to see whether 
the bleeding is stopped, the patient is put to bed, the foot of the 
bed being elevated. 

If the pressure does not control the haemorrhage, the patient 
is placed in Sims's position and given chloroform. All dressings 
are removed and the bleeding vessel sought for. Descent of the 
intestines is prevented by gauze pads, the bladder is sharply re- 
tracted with the trowel, while the perinaeum is held back by a 
Sims's speculum. When the spouting vessel is seen, it is grasped 
with bullet forceps, which take a firm hold on the tissues, and the 
stump is lifted away from the vaginal wall. It is then an easy 
matter to grasp the stump with forceps. The vagina is to be 
packed with iodoform gauze. If, after searching carefully, the 
bleeding is seen to come from above the vaginal vault and the 
vessel cannot be found, the haemorrhage springs from an ovarian 
artery. When the operator is convinced that this is the case, he 
does not attempt to secure the vessel through the vagina with for- 



HYSTERECTOMY FOR PELVIC SUPPURATION 325 

ceps, nor to compress it with gauze, but, after packing the vagina 
with gauze, to prevent descent of the intestines, he throws the 
patient into Trendelenburg's position and opens the belly. When 
he has found the source of the bleeding, the artery is tied with 
chromic tendon and the stump trimmed. The same is done with 
the other ovarian artery. The ligatures are cut short and the 
pelvis cleared of clots. The abdomen is closed. It is well to 
give a high enema of 3 pints of salt solution before the patient 
leaves the table, or to inject sterile filtered normal salt solution 
into a median cephalic vein. I have seen this accident but twice. 

If it be found that the bleeding comes from the azygos artery 
or other vaginal branch, it is best secured by passing a curved 
needle around it and tying en masse with silk. I cannot conceive 
it possible that so tortuous and long a vessel as the ovarian artery 
can bleed after its current has been completely shut off for two 
days. It is probable that it bleeds because the occlusion has been 
partial and incomplete, and after the removal of the forceps the 
blood stream bursts through whatever clot has formed in the 
vessel. It is not so with the uterine artery. After this vessel is 
clamped, but little of its length remains between the forceps and 
the internal iliac artery, and consequently, when the forceps is 
removed, the end of the artery feels the full force of the pressure 
from the iliac. 

I cannot explain the very late haemorrhage occasionally oc- 
curring when the patient is ready to get up, except upon the hy- 
pothesis that the repatency of the artery becomes established. 
That this does occur I have shown. It has been observed after 
abdominal hysterectomy with ligature, and has heretofore been 
ascribed to bleeding from anastomotic vessels. It is always from 
the uterine artery or its branches, and is easily checked by for- 
ceps applied through the vagina. 1 

1 The author demonstrated by an autopsy upon an injected cadaver who 
had been subjected to a vaginal ablation many years before, silk ligatures hav- 
ing been employed, that the uterine artery becomes patent after a time. 



CHAPTEE XVIII 

THE OPERATIVE TREATMENT OF CARCINOMA OF THE 

UTERUS 

This is of two very distinct and markedly differing kinds: 
those procedures which may be called radical and those which 
are solely palliative. 

INDICATIONS FOR THE SEVERAL RADICAL OPER- 
ATIONS FOR CANCER OF THE UTERUS 

Of the Cervix Uteri. — As a general proposition it may be 
stated that whenever malignant disease of the cervix is discov- 
ered and is limited to the uterine tissue a radical operation is 
indicated. In certain cases the general condition of the patient 
may be so poor that to subject her to a grave operation would 
be fraught with too great danger. Advanced lung disease, ne- 
phritis, and mitral disease, as a rule, contra-indicate ablation of 
the cancerous uterus. As a converse proposition, it may be laid 
down that whenever the cancer has extended beyond the uterine 
tissue, radical work is out of the question. Such extension re- 
veals itself in a greater or less density in the pericervical tissues, 
fixity of the cervix, and, remotely, glandular enlargements. But 
these conditions are also brought about by inflammatory lesions, 
and these latter must be eliminated as causes for the fixity of the 
cervix before the propriety of a radical operation can be deter- 
mined. There is a surgical rule with its corollary, that 

ALL OPERATIONS FOR CANCER SHALL PROCEED THROUGH NORMAL 
TISSUES, AND THAT NO RADICAL OPERATION SHOULD BE ATTEMPTED 
UNLESS THE SECTION OF THE TISSUES CAN PASS OUTSIDE THE 

cancerous field. For the scope of any proposed operation is 
326 



CAKCINOMA OF THE UTERUS 327 

determined not so much by the fact that this or that fraction of 
tissue is involved in the cancerous invasion as by the tendency 
of cancer to recur after removal. And the merits oe any oper- 
ation FOR THE RELIEF OE THIS CONDITION ARE DETERMINED BY 
THE ULTIMATE RESULTS RATHER THAN BY THE IMMEDIATE. Good 

ultimate results are not to be expected when the cancer has ex- 
tended beyond the uterus. And furthermore, the less the in- 
volvement of the uterus itself the better the remote results follow- 
ing operation. Therefore, cancer which is diagnosticated by the 
microscope is less likely to recur than that which is revealed by 
the symptoms it produces. So, then, the earlier cancer is diag- 
nosticated the clearer the indications for radical operation and 
the better the results from such operation, both immediate and 
remote. Even when bimanual examination demonstrates that the 
uterus is perfectly movable, cystoscopic examination will often 
show that the cervico-vesical wall is involved. This involvement 
will cause rounded elevations beneath the vesical mucosa. 

The great problem which confronts the surgeon is the deter- 
mination of the distance from the cancer field at which his section 
of the tissues must proceed. It may be stated that in epithelioma 
the tissues may be severed closer to the involved field than in 
adeno-carcinoma. Whether this clinical observation is due to the 
lesser virulence and slower progress of epithelioma or to the fact 
that as a rule epithelioma is usually, because of the nature of its 
growth, discovered sooner than adeno-carcinoma, I do not know. 
But it is my belief that epithelioma of the cervix is far less 
malignant than adeno-carcinoma. However, the rule in operating 
is to keep as far away from the cervix as possible. There are 
two routes for operating upon cancer of the cervix: the vaginal 
and the abdominal. And of all cases of cancer of the uterus 
which come to us for treatment, scarcely 10 per cent can be sub- 
jected to any radical operation. 

(a) Indications for the Radical Vaginal Operation. — These 
are to be found in the immediate mortality and in the ultimate 
results. 

The death-rate from vaginal hysterectomy in cancer of the 
cervix should not be more than 5 per cent. It is most difficult 
to determine precisely the ultimate results because so many pa- 
tients are lost sight of, and the groups of cases falling in the 
hands of different operators vary so much in the extent of the 
21 



328 



GYNECOLOGY 



involvement. Of all cases operated upon by the vaginal route, 
about 60 per cent recur within the first year after operation. 
Of the remainder, not more than 20 per cent are free from 
recurrence after five years. And these results are found by those 
who are thorough masters of technique. 

Vaginal hysterectomy for cancer of the cervix is an operation 
which can be rapidly performed and does not necessitate a pro- 
found degree of narcosis. It is therefore indicated in those who 
are aged and who would not for other reasons stand a more severe 
and prolonged operation. If it is indicated at all, it is in old 
women, in very stout women, and those with nephritis or cardiac 

disease, who are suffering from 
epithelioma. It is the au- 
thor's belief that a less severe 
operation gives results equally 
good remotely and far better 
immediately. I refer to the 
high amputation of Dr. John 
Byrne. And when we reflect 
that the radical vaginal op- 
eration is limited to cervical 
cancers which have not ex- 
tended beyond the uterus, 
while the procedure of Byrne 
is applicable, and always with 
benefit, to all cases which have 
not actually invaded the blad- 
I j 1 der or bowel, we can see the 

WJ'l |M greater value of Byrne's op- 

^^ W/ BfeS ^^ eration. 

^^^^j The Operation. — The pa- 

tient is placed on the back in 
the lithotomy posture. All 
necrotic and cancerous tissue 
about the cervix should be 
scraped and cut away. The 
cervix is then closed by a 
series of heavy silk sutures. These effectually prevent soiling the 
wound by cancer elements and furnish excellent traction strings. 




Fig. 135. — Ablation en Masse. 

The forceps are shown grasping the bases 
of the broad ligaments upon both sides, 
and the tissues have been cut so as to 
free the cervix upon all sides. 



The uterus must be removed 



en masse. 



and without hemisection 



CAKCIXOMA OF THE TTTEKTTS 



329 



and morcellation. The cervix is now entirely circled either by the 
scissors or cautery knife, preferably the latter. The line of in- 
cision must be as far away from the cervix as possible : posteriorly 
at the lowest limit of the pouch of Douglas, laterally near the 
ureteral lines, and anteriorly at that point beneath the bladder 
which will just escape enter- 
ing that viscus. Approxi- 
mately this cuff of cervical 
tissue will not be over J of 
an inch in depth (Fig. 139). 
The posterior, anterior, and 
lateral vaginal walls are re- 
tracted by assistants, one of 
whom pulls the cervix down. 
The operator now carefully 
dissects up the vaginal cuff 
by means of toothed forceps 
and scissors. He next enters 
the posterior cul-de-sac and 
extends the lateral margins 
of this incision by his fingers 
until the bases of the broad 
ligaments are reached. Into 
this posterior opening a gauze 
pad is introduced to catch 
fluids and prevent prolapse 
of the intestines. The oper- 
ator then turns his atten- 
tion to separating the blad- 
der from the uterus. This 

must be accomplished slowly by means of the toothed forceps and 
scissors, more rapidly by using the index finger to peel up the 
vesical tissues (see Vaginal Hysterectomy for Pus). When the 
vesico-uterine fold of peritonaeum has been severed the lateral 
borders of the anterior incision are extended by means of the 
fingers. The uterus now hangs by its lateral supports only. It 
is important to release the ureters from their associations to the 
loose tissue about the cervix. This is accomplished by gently 
shoving the tissues away from the cervix first on one side, then 
on the other, anteriorly and posteriorly. It may be doubted 




Fig. 136. — Ablatio:* en Masse. 

The free cervix has been shoved up and the 
fundus drawn down. The bullet forceps 
are shown fastened into the fundus, and 
the cornua uteri are seen. 



330 



GYNAECOLOGY 



whether the ureters can be laterally displaced in this manner. 
I have many times demonstrated it upon the cadaver. This sepa- 
ration of cervix from ureters is still further increased by drawing 
down the uterus and lifting the bladder with the trowel. While 
this is being done one index finger is introduced behind the uterus 
and the tissues upon one side then upon the other are grasped by 
forceps. The bases of the broad ligaments upon each side are in 
this manner grasped, together with the uterine arteries. Before 
the forceps are locked they should be slowly worked outward as 
close to the ureters as possible and without wounding them. After 
locking the forceps the tissues are cut close to them up to the 

points of the forceps. These 
two forceps must also em- 
brace the insertions of the 
utero-sacral ligaments. The 
uterus now hangs by the tops 
of the broad ligaments and 
the round ligaments. In 
order that these may be se- 
cured without risk of wound- 
ing the gut, the cervix is re- 
leased and the body of the 
uterus delivered beneath the 
bladder. The ovaries are 
drawn out also and held by 
suitable forceps. A forceps 
is then applied from above 
downward upon the right 
side outside the ovary, with 
its points lapping the forceps 
below and internal to it. The 
broad ligament and round 
ligament are cut and the 
uterus swings out of the pel- 
vis. It is an easy matter now 
to grasp the ovarian artery 
on the left side and remove the uterus. If the operator prefers to 
do so he may now substitute ligatures of stout tendon for the for- 
ceps. These ligatures are passed by the large aneurysm needle first 
to the bases of the broad ligaments and then to the tops. I always 




Fig. 137. — Ablation en Masse. 
All retractors have been removed. The hand 
is shown grasping the right ovary and tube 
and fundus uteri. The forceps is grasping 
the top of the right broad ligament. 



CARCINOMA OF THE UTERUS 



331 



ligate the round ligaments separately to guard against their pulling 
out of the loop of the ligature, thus loosening it and causing sec- 
ondary haemorrhage. Care must be exercised in removing the for- 
ceps lest the stumps slip away from the operator. He should at- 
tach a fine artery forceps to the cut end of the artery, and then, as 
an assistant loosens the large forceps, the operator ties down hard 
and makes the second knot 
as rapidly as possible before 
the elasticity of the stump 
loosens the first knot. My 
individual preference is for 
the use of the forceps exclu- 
sively. If this is done, the 
wound is dressed as in the 
similar operation for pus. If 
ligatures are used these are 
cut short and the stumps al- 
lowed to retract upward. The 
centre of the wound is then 
closed by several sutures of 
tendon which unite the an- 
terior and posterior cut 
edges of the vagina. Intra- 
abdominal pressure will force 
the peritoneal edges to- 
gether. A snug drain of 
iodoform gauze is inserted 
upon each side up to the 
stumps of the uterine arter- 
ies so as to prevent prolapse 
of the intestines or omen- 
tum, and the vagina is 

loosely packed with iodoform gauze. If ligatures are used the 
stumps do not slough, while forceps, if left on, always cause 
slough. It is because of this effect of forceps that I always use 
them. With ligatures the stumps remain vitalized, while with 
forceps they come away. Therefore forceps remove more tissue 
than the ligatures, and broad removal of tissue is what we de- 
sire when operating for cancer. The dressings are removed and 
renewed in seven da vs. 




Fig. 13S. — Ablation en Masse. 



The uterus swings out of the body when the 
right broad ligament is severed. The last 
forceps is shown grasping the top of the 
left broad ligament. 



332 



GYNAECOLOGY 



(b) Indications for Abdominal Ablation of the Cancerous Ute- 
rus. — Inasmuch as the abdominal operation allows the operator to 
secure the ovarian vessels at the pelvic brim and the uterine 
arteries outside the ureters — as by this operation not only the in- 




Fig. 139. — Specimen removed en Masse by the Vagina in Early Cancer of the 

Cervix. 



dividual lymph glands, but the lymph channels in the broad 
ligaments can be removed, as well as all the vagina, if necessary — 
I always perform this operation for cancer of the cervix if a 
radical operation is indicated. The operation permits the broad- 
est section of tissue in an uninvolved field with accurate removal 
of lymphatics, thus complying with the first surgical requisite. 
It further admits of this being done under a preliminary hsemo- 
stasis, and the vessels and lymphatics are severed before the uterus 
is subjected to any squeezing, thus eliminating the possibility of 
extrusion of the cancer elements into the absorbents. Further- 
more, complications can be better dealt with by this route. The 
abdominal route permits the surgeon to remove all those struc- 



CAKCINOMA OF THE UTEEUS 333 

tures to which cancer normally extends and in which it has a 
tendency to recur. And it does this to the satisfaction of every 
requisite of the surgical treatment of cancer. In some quarters 
there is a tendency to apply the vaginal operation to the early 
cases, reserving for the abdominal operation those in which 
there are complications or in which extension of the cancer out- 
side of the cervix has taken place. If cancer were free from 
the tendency to recur, such a selection might be proper, but by 
adopting such tactics the operator is neither just to the oper- 
ation nor to .his patient. If the abdominal operation is the 
preferable procedure for, and grants any sort of protection to 
those who have cancer with complications, it is indicated with 
still greater insistence in the early cases. No one has the right 
to rob a patient suffering from cancer of even a fraction of a 
per cent of immunity from recurrence. In all cases it is the 
surgeon's duty to do the most radical operation possible pro- 
vided this complies with the surgical and anatomical require- 
ments of the case and does not carry a prohibitive mortality. A 
woman with early cancer has greater right to a radical operation 
than one with the disease in a later stage, for her chances of 
recovery and immunity against recurrence are greater. 

The operation has been before the profession for too short a 
time to justly estimate the ultimate results. It has been per- 
formed by me 34 times with 3 deaths, 8 T 8 o per cent mortality. 
In no case in which the parametrium was not already involved 
has there been recurrence in a year. The first operation was done 
five years ago, and the patient is still alive, free from recurrence. 
The causes of death were angina pectoris due to arteriosclerosis, 
nephritis, and endarteritis obliterans, each 1 case. An extended 
report will be made at a future date. Enough has been said here 
to furnish reasons for the procedure. 

The Operation. — The Vaginal Stage. — The uterus is curetted 
and all cancerous spots are cut away. The cervix is then thor- 
oughly roasted with the dome-shaped cautery. The vagina is now 
cleansed, and a self-retaining catheter introduced and left open 
to drain the bladder. This stage has been conducted by the first 
assistant, who now resterilizes his hands. The patient is placed 
in position for laparotomy. 

The Abdominal Stage. — A median incision is made from the 
pubis to the umbilicus. It is necessary to go through the pyram- 



334 GYNAECOLOGY 

idalis muscle down to the pubic cartilage. And if the woman 
be fat, the umbilicus is removed and the incision extends above 
this. Upon entering the abdomen the table is lowered into the 
exaggerated Trendelenburg position. The intestines and omen- 
tum are gently taken from the pelvis and placed in the abdomen, 
and the sigmoid is straightened out. The curvature of the loins 
upon each side of the spine above the pelvic brim are carefully 
and accurately filled with gauze pads, and other pads are used so 
as to make a complete dam across the body at the upper end of 
the incision holding the intestines back. The table is now raised 
so as to be almost horizontal. A careful survey of the field is 
made, but rapidly. I then pick up the ovarian vessels of one 
side at the pelvic brim before they cross the external iliac artery 
and ligate them. Provisional ligatures are then applied near the 
ovaries. The same is done on the other side. The broad liga- 
ments between are cut close to the first ligatures, which latter are 
cut short. The round ligaments are seized by artery forceps, drawn 
out, ligated close to the internal inguinal rings, and cut short. 
Beginning upon the right side the peritonaeum is split upon a 
director from the point of first cut, along the pelvic brim below the 
external iliac artery to the vesico-uterine fold. This having been 
done on each side and the two cuts united by a third across the 
bladder at the vesico-uterine fold, the peritoneal covering of the 
organs to be removed is severed at all points except posteriorly. 
Using the fingers only, I push the lower flap of peritonaeum on one 
side, in which should be the ureter, away from the upper, feeling 
for the pulsation of the common iliac artery. This blunt dissec- 
tion proceeds down into the pelvis until the internal iliac is found. 
At a point over this, about \ an inch below the bifurcation of 
the common iliac, the internal iliac is carefully exposed. For 
this purpose I use toothed forceps and Sims's blunt vesico-vaginal 
scissors. It will be seen that the artery is accompanied by one 
vein, which usually lies below it, sometimes by two. The aneu- 
rysm needle is passed unthreaded around the vessel from within 
out. It should be threaded with a chromic tendon -^ of an inch 
in diameter, perfectly round and tested. This is drawn around 
the vessel. The first knot is made with one turn of the strand 
and tied. It should be tied slowly without lifting the artery, 
and by a pressure of 2 pounds so as to approximate without rup- 
turing the intima walls. The second knot is carefully tied. If 



CAECIXOMA OF THE UTERUS 335 

pulsation is found below the ligature another is passed and tied. 
The ligatures are cut short. To one side of the bladder beneath 
the horizontal pubic ramus the loose areolar tissue and fat is 
spread apart by the fingers so as to expose the white obturator 
nerve. This is traced to the obturator foramen. At this point 
the obturator artery and veins are exposed, usually below the 
nerve. The needle is passed around the vessels, carrying a fine 
tendon, and the vessels are ligatured. The variations of the ob- 
turator artery must be borne in mind at this stage. The ligations 
are repeated upon the other side. These eight preliminary liga- 
tions have cut off all blood supply through the ovarian, round 
ligament, uterine, superior vesical, pubic, obturator, gluteal, and 
sciatic arteries, and sometimes through the ileo-lumbar. The 
field of operation will be bloodless except from severed veins and 
anastomoses low down in the pelvis. I next dissect out the ureters 
to the point where they pass beneath the uterine arteries, ligate 
these arteries at their origins from the internal iliacs as a pre- 
caution, and trace the ureters forward well up to their insertion 
into the bladder. All fat in the obturator foramina about the 
upper third of the vagina and between the iliac vessels, together 
with all glands which are visible, are now removed. Particular 
attention is paid to the bases of the broad ligaments and obtu- 
rator foramina, to remove all lymphatics and glands. ■ While the 
ureters are held up, the operator dissects the bladder from the 
uterus and upper half of the vagina. In freeing the ureters they 
should be dissected entirely away from the peritoneal flaps, other- 
wise much fat will be left clinging to them. I usually at this 
stage ligate, as a precaution, the superior vesical and other an- 
terior branches of the internal iliac close to the main artery. The 
uterus is now held high up so as to put the vagina and utero- 
sacral ligaments on the stretch, and the vagina and utero-sacral 
ligaments, with their peritoneal covering, are circled by the scis- 
sors below the upper third of the vagina. Deep down in the pelvis 
the erectile tissue of the vagina will be found bleeding. This is 
grasped and ligated. All loose bits of fat above the bases of the 
broad ligaments, between the iliac arteries and between the severed 
utero-sacral ligaments, are picked out, If the venous bleeding is 
troublesome the patient may be lowered into Trendelenburg's posi- 
tion while the operation is finished. The vagina is held open by 
two forceps and several rolls of gauze are introduced, their ends 



CARCINOMA OF THE UTERUS 337 

projecting above the vagina. The ureters are returned to their 
beds and the peritoneal flaps adjusted by interrupted sutures as 
far as possible. Upon each side a suture should pass through the 
round ligament, which is stout, and then through the fold of 
peritonaeum at the sides of the rectum. It is unnecessary to suture 
the rectum to the bladder, as they will fall together. 

The field of operation having been closed out, the retaining 
pads are removed, the sigmoid and omentum brought down, and 
the abdominal wound closed. The wound is dressed and the pa- 
tient placed in the lithotomy position. The vaginal dressings 
are examined and adjusted. In doing this the livid hue of the 
vulva and buttocks will be noticed, due to the ligation of the 
internal iliacs. The patient is given a high enema of 1 quart 
of warm saline solution containing 2 ounces of whisky. This is 
done by dropping the head of the table and not by inserting a 
long rectal tube. If shock is present it is to be treated as detailed 
elsewhere. The vaginal dressings are removed and renewed in 
ten days. 

HIGH AMPUTATION 

Indications. — In the author's opinion, the few cases which can- 
not stand the strain of the perfected abdominal operation will re- 
ceive a better ultimate result with less immediate risk from the 
operation under discussion than from vaginal hysterectomy. It 
has been shown that cancer of the cervix has little tendency to 
ascend above the internal os. It is, therefore, in operating for 
cancer of the cervix, not necessary to proceed above the internal 
os. The true indication is eor a removal of the upper 

THIRD OF THE VAGINA AND THE PARAMETRIC TISSUE AND GLANDS 

outside tfie ureter. This is accomplished only by laparotomy, 
never by vaginal hysterectomy. Vaginal hysterectomy may then 
be termed an operation of purely local application, such as is 
amputation of the mamma without muscular and glandular ex- 
tirpation. It will be seen how thorough the high amputation 
and cautery is. 

The Operation. — The patient may be in either the lithotomy 
or Sims position. I prefer the former. Wooden retractors are 
preferable. If metal are used they must be frequently cooled by 
iced water. The uterus is curetted and the cervix amputated by 
Sims's method. The diver £hw tenaculum is then introduced into 



338 



GYNECOLOGY 



the uterine canal and the excavated stump drawn down. A 
sharp-pointed knife, curved on the flat, is inserted into the tis- 
sues, and a hollowed cone of tissue is removed. The tenaculum 
is again introduced and another cone removed. This is repeated 
until the uterus is excavated, so that upon digital examination 

nothing remains of 
the cervix but a thin 
shell of tissue. The 
cavity resulting leads 
by a broad opening 
into the uterine cav- 
ity, and there should 
be no constriction at 
the former site of 
the internal os. The 
wound made by the 
successive applica- 
tions of the knife 
should open down- 
ward as a cone with a 
broad base. 

The operator now 
inserts the dome- 
shaped electrode cold 
to the fundus uteri 
and turns on the cur- 
rent sufficiently to 
heat the knife white. 
It is held in one position until all bleeding stops and the adjacent 
tissues are charred black. This takes about fifteen minutes. The 
heat radiates in all directions, and while being applied frequent 
applications of gauze wrung out in iced water are to be made 
to the vaginal retractors. The staff of the cautery must, of 
course, not be allowed to touch the retractors. After cooking 
the corpus uteri the current is turned off and the cautery is 
withdrawn to the cervix. If it is found to be caught it is be- 
cause the cervix has not been properly excavated by the knife. 
The cautery is now held within the cervical excavation and the 
current turned on. Not only should the heat convert the re- 
mains of the cervix into a carbonized mass, but the grayish tint 




Fig. 141. — First Step in High Amputation of Cer 

VIX — MAKING THE CIRCULAR INCISION (SAGITTAL Sec 



tion). (Byrne.) 



CAKCIJSTOMA OF THE UTEEUS 339 

assumed by the adjacent vagina shows that it, too, is destroyed. 
As the cervical cavity has been thinned out, less time is required 
to destroy it than in the case of the corpus. In fact, the corpus 
is so thick that the area of carbonized tissue protects it, and I 
have never seen it all slough away. The application of the cau- 
tery to the cervix must be most thorough. It is more often in- 
complete than proper. It is almost needless to say that the heat 
produces a sterilized wound. It must also undoubtedly destroy 
the pericervical tissues for quite an area, particularly the less 
vitalized cancer cells. 

The wound is not packed, but when discharge begins the pa- 
tient is put on mild antiseptic douches. Surprisingly little pain 
results. Advanced cases are no bar to the operation. It has a 
retarding effect upon all. Instead of removing the tissues by 
knife and then applying the cautery, the entire operation may 
be performed by the cautery knife (Fig. 1^1), but more slowly. 

The Treatment of Advanced Carcinoma Cervicis Uteri. — This 
embraces removal of all sloughy and necrotic tissue so far as 
possible to secure local cleanliness. During the application of 
the curette and scissors frequent digital examinations should be 
made to determine the thickness of the tissue remaining around 
the cavity. Should the peritoneal cavity or the rectum or bladder 
be entered the patient's danger is much augmented. If the peri- 
toneal cavity is entered it should be drained, not sutured; and if 
the bladder or rectum be wounded suture is useless, for cancerous 
tissues will not unite, so the organ entered must be kept empty 
in the hope, usually vain, that the opening will close; in the first 
instance by catheter, in the latter by rectal tube. In cases where 
there has been no damage to any adjacent organ, after all slough- 
ing tissue has been cut and scraped away the bleeding is to be 
checked by the application of the galvano-cautery. A superficial 
slough will be produced by this which in a few days will separate, 
leaving a granulating wound. Further removal of tissue can be 
secured by the following method of treatment : thin circular pieces 
of cotton about -J an inch in diameter are squeezed out in aqueous 
solution of chloride of zinc of 20-per-cent strength. These are 
packed snugly all around the cervical cavity so as to completely 
fill it. Over the whole the vaginal vault is packed with large 
pieces of cotton wrung out in a saturated solution of bicarbonate 
of soda. This is essential, because as the serum percolates through 



340 GYNAECOLOGY 

the zinc-laden cotton it would cauterize the vagina unless caught 
and neutralized by the soda solution. 

The dressing is left in two days. Upon its removal the cervical 
cavity will be lined by a greenish slough. Two days later this 
can be picked away by forceps. In this way repeated sloughs can 
be produced and removed. When the physician has no cautery, 
this caustic treatment can be begun after the operation for re- 
moval of the cancerous outcroppings as soon as the bleeding has 
ceased. I have tried all the various methods of local treatment 
and find this the simplest and most efficacious. Immediately upon 
the completion of this treatment the patient should be put on 
thyreoid extract. I have seen in many cases good results follow, 
and in no case have I failed to see the disease arrested for a time 
at least. The thyreoid should be pushed to the point of tolerance. 1 

Pain in carcinoma must be relieved by opiates. At first codeine 
suppositories are employed, then the stronger preparations. 

Section of the spinal nerves I cannot recommend. 

Hemorrhages occurring during the course of cancer are best 
treated by tamponade with vinegar-soaked cotton. 

As the pelvis becomes blocked with cancer masses, obstruction 
of the bowel may occur. It is then the surgeon's duty to perform 
colostomy. 

In treating these unfortunate women it is the physician's 
duty to prolong life as long as possible and to relieve pain. To 
wittingly allow the patient to die sooner than she would were she 
stimulated and nourished is committing a sin by omission. To 
purposely shorten her life by the administration of overwhelming 
doses of morphine or by the performance of surgical operations 
which must inevitably result in death is criminal. The physician 
did not give the life, nor has he the right to passively or actively 
shorten it. He cannot be the judge in such matters, nor has he 
authority in law or morals for any act which will shorten life. 
I am constrained to approach the ethical phase of this subject, 
because certain teachers are pleased to advise shortening the life 
of the sufferer. 

The author devised, and has in a number of instances prac- 
tised, the application of ligatures to the vessels which nourish the 

1 I employ that made according to the formula of Dr. C. G. Am Ende, and 
give one capsule twice a day. 



CARCINOMA OF THE UTERUS 341 

malignant growth. The observation had for many years been 
made by the older surgeons, and more recently emphasized by 
Dawbarn, that the malignant growths shrink after the nutrient 
vessels are ligatured. In sarcoma this is particularly noticeable, 
large growths entirely disappearing. In epithelioma and carci- 
noma the changes are not so noticeable, but are sufficiently marked 
to arrest our attention. Therefore, in every young woman 

WITH CANCER SO EAR ADVANCED AS TO PRECLUDE THE POSSIBILITY 
OF A RADICAL OPERATION, I ALWAYS LIGATE THROUGH THE MEDIAN 
ABDOMINAL INCISION, THE OVARIAN, THE INTERNAL ILIAC, AND 
OBTURATOR ARTERIES. 

No attempt is made to remove any tissue, and only enough 
incision is made into the peritonaeum to enable the operator to 
reach the vessels. After completion of this operation the cancer 
masses are scraped away through the vagina, and every facility 
offered for the freest escape of the necrosing tissue. The patient 
is put upon thyreoid extract and tonics. By this treatment life 
is much prolonged and suffering diminished. 



CHAPTEK XIX 
HERNIA 

Because the pelvic floor in women is so elastic under an increase 
in the intra-abdominal pressure, those hernias which are common in 
men are infrequent in them. Women are particularly prone to um- 
bilical and ventral hernias, the latter due to weakness in the scar 
of a laparotomy wound. We meet with ventral, umbilical, fem- 
oral, and inguinal hernias in women, and in frequency in the 
order mentioned. 

Median Ventral Hernia. — There is a greater or less separation 
between the rectus muscles and their fasciae in the line of the 
incision. It is probable that at first this diastasis is very slight. 
In the beginning but a small portion of the omentum bores its 
way between the musculo-fascial edges, and upon escaping be- 
comes oedematous and enlarged through constriction at the her- 
nial ring. Thus greater tension is produced outside the ring 
than exists within, and more omentum is drawn out. As the 
ring enlarges the small intestine enters the sac. 

The hernial sac is composed of skin, fat, and peritonaeum, or the 
fat layer may be entirely wanting, the viscera lying directly under- 
neath the skin, so that intestinal peristalsis may be seen through the 
skin. Occasionally a patient will be met who has an enormous 
hernia, most of the intestines lying outside the abdominal cavity. 
Pressure ulcers in the skin over the protrusion may be present. As 
a rule the omentum and intestines are more or less adherent to 
the edges of the ring and sac. There is little tendency in ventral 
hernia to become strangulated, for, after once forming, the ring 
very soon assumes proportions sufficient to preclude strangulation. 
Ventral hernias should be closed as soon as found. While small, 
little difficulty is experienced in doing this, and the results are 
uniformly good; but after a large mass of intestines has for some 
time been outside the abdominal cavity it can be returned with 
342 



HERNIA 343 

difficulty, and is retained against the continuous contraction of 
abdominal muscles which are unused to its presence. In other 
words, in old cases of ventral hernia of large size the abdominal 
cavity is actually smaller than normal. 

In order to successfully close a ventral hernia it is necessary to 
secure the most perfect union between the muscles and fascia upon 
the separation between which the hernia depends. The operator 
should not cut directly down upon the hernial sac lest he wound an 
adherent knuckle of gut. The first incision should be curved and 
should be just over one edge of the ring. The incision proceeds 
down through normal anatomical layers: the skin, fat, external 
lamella of the rectus fascia, the rectus, the internal lamella of its 
fascia, and the peritonaeum. If the sac is first entered the perito- 
naeum is at once opened, and then the surgeon must cut through 
one side of the hernial ring in order to expose the fascial planes and 
muscle. It is safer to enter the abdominal cavity as described 
through normal anatomical structures so as to be in a position to 
inspect and deal with any existing complications from the visceral 
side. After all adhesions have been severed, the viscera are returned 
to the abdomen, and protected by a gauze pad placed over them 
and under the hernial ring. The redundant portions of the sac 
and skin are cut away, and the wound now appears as an ordinary 
laparotomy wound. There is this difference, however, that in the 
operation for the radical cure of ventral hernia there are two fascial 
planes to be united. If one only is seen the operation has been 
improperly done, because the operator has failed to cut away the 
scar-like tissue which lies over the muscles and fascia and which, 
covered as it is by peritonaeum, very much resembles the linea 
alba. The peritonaeum should be closed by a fine continuous tendon 
suture. The lower lamella of the rectus fascia and the rectus are 
brought together by one set of interrupted sutures of fine chromic 
tendon, the outer fascial lamella by another, and the skin and fat 
separately closed. If there is much tension in the line of union 
it may be relieved by sutures of silver wire which pass through all 
the anatomical layers and the ends of which emerge an inch outside 
the line of union. These sutures are not twisted, but are fastened 
by split shot. 

As many of these hernias are due to suppuration in the lapa- 
rotomy wound, much scar tissue may be met with about the edges 
of the hernial ring. This should all be cut away and healthy 
22 



344 GYNAECOLOGY 

muscle and fascia exposed. If the patient is very fat and the 
intra-abdominal pressure great, the outer lamella of fascia may 
be brought together with No. 27 silver wire, which is twisted 4 
times, laid flat and cut short. These sutures are practically per- 
manent, but only occasionally will they produce pricking sensa- 
tions in after years. This method of suturing is particularly in- 
dicated in patients who have a chronic cough, and in case there has 
been much loss of muscle and fascia through sloughing. It is 
contra-indicated in very thin women. But in them the outer 
lamella of fascia may be brought together by the same suture 
that closes the skin and fat, and can then be of silver wire, which 
may be removed a month or so later. 

In certain cases, after he ha& made his dissection, the operator 
will find that he cannot bring the edges of the muscle and fascia 
together. He will then proceed as follows : the peritonaeum is closed 
by a running suture and the internal lamella of fascia approximated 
if possible, but if not it is ignored. The operator then dissects the 
fat up from the upper lamella of fascia for an inch upon each side 
by blunt dissection. He now cuts through the fascia upon each side 
in lines parallel with the abdominal wound. This will allow the 
rectus to slide inward and the outer lamella of fascia to be approxi- 
mated across the wound. The rest of the wound is then treated in 
the usual way. 

When the patient is very stout the procedure devised by me 
many years ago may be adopted. After closing the peritonaeum 
and inner lamella of fascia with tendon sutures, I bring the mus- 
cle and outer lamella together with interrupted silver-wire sutures 
which are twisted and left long sticking up in the wound. No 
attempt is made to close the fat and skin, but they are kept apart 
by iodoform-gauze dressings. The silver-wire sutures are removed 
in three weeks. If found embedded in new cells the wires are 
untwisted and their loops thus exposed are cut, rather than the 
loops sought directly by digging for them. A wound so treated 
closes in about eight weeks by the formation of a mass of histo- 
logical connective tissue through which no hernia can ever take 
place. The wound does not granulate, merely fills in. This pro- 
cedure takes advantage of the law that, under normal conditions, 
the offspring of every tissue resembles the parent. The cells which 
close the wound spring from the connective-tissue plane and become 
connective tissue. 



HERNIA 345 

It is advisable to keep herniotomy cases in bed until all risk 
of stretching the reunited structures is passed. I insist upon not 
less than four weeks in bed. Thus it is seen that many different 
techniques are required in dealing with the various forms of 
this distressing sequela of laparotomy. 

Umbilical Hernia. — This is not, as is usually taught, a hernia 
through the umbilical ring. The mass of connective tissue which 
closes this opening is so firm that it cannot stretch. In adults 
the hernia comes out to one side of the ring. Occasionally we 
find congenital umbilical hernias of small size in the coloured 
children of the South which come through the umbilical ring. 
I have never seen one in a white adult. As a rule umbilical 
hernias are small, but may be so large as to contain the stomach. 
As the hernia forms through normal structures and not through 
a wound line, its ring is small and strangulation particularly 
liable. These hernias are most often seen in obese women. In 
them fatty heart and bronchitis are common. Therefore, opera- 
tions upon them are accompanied by a mortality not seen in 
other herniotomies. The same principles govern the operation 
for the relief of umbilical hernia as ventral hernia. It is neces- 
sary to dissect out the umbilicus and the surrounding fascia 
until the rectus is exposed upon each side with its two fascial 
lamellae. The linea alba is broader at the umbilicus than below, 
and hence there is more tissue to dissect away before exposing 
the recti. 

When called to a case of strangulated umbilical hernia no 
attempt should be made to effect a radical cure. The operator 
cautiously opens the sac at its lower border and incises the 
ring in the middle line. The viscera are then carefully freed 
from the several pockets in which they lie in the main sac, and 
are returned to the abdomen. The skin is then closed and a 
large, firm dressing applied tightly enough to retain the viscera 
within the abdomen. This may be found impossible, and then 
the operator merely incises the ring to relieve the strangulation 
and closes the skin with silver wire. This can all be done under 
cocaine anaesthesia. The radical operation can follow in a few 
days after all symptoms of strangulation have disappeared. 

Femoral Hernia. — The intestine or omentum escapes beneath 
Poupart's ligament usually internal to the femoral vein. So 
complicated is the anatomy when viewed from in front that I al- 



346 GYNAECOLOGY 

ways perform a low median abdominal section in dealing with 
this condition. This is particularly insisted upon when strangu- 
lation exists or the hernia is incarcerated, one of which conditions 
exists in over half the cases coming to us for relief. After the 
abdomen is opened the viscera are drawn out of the sac and any 
complications dealt with. All the vessels about the ring are read- 
ily seen. The closure of the sac is now a simple matter and is 
effected by 3 chromic-tendon sutures. Care must be exercised 
not to wound the external iliac vein. The sutures pass through 
the lower border of Poupart's ligament, which they unite to the 
pubic fasciculus of the fascia lata. 

If the surgeon prefers to operate directly upon the hernia, 
without opening the abdomen, he makes an incision over the her- 
nia and enters the sac. The intestine is then returned and the 
sac freed, ligated, and cut away. A few sutures suffice to unite 
Gimbernat's ligament to the pubic fascia lata. The skin may be 
left open and packed with gauze, the opening closed by a con- 
nective-tissue hyperplasia, or else the skin may be sutured. I 
prefer the former method, as it gives a firmer scar. 

Inguinal Hernia. — The operation for this, as a rule, is exceed- 
ingly simple. An incision is made over the sac and parallel with 
Poupart's ligament. Upon exposing the sac, this is lifted up and 
freed from the round ligament. The sac is then liberated from 
its contents and a stout tendon ligature is passed around its neck 
and tied once. The sac is now opened to make sure that it does 
not contain any omentum or other tissue, and the ligature around 
the sac is tied tightly. The sac is then cut away. In approaching 
the sac a few fibres of intercolumnar fascia may have to be sev- 
ered, after which the section of tissues proceeds as described in 
the article on Alexander's operation. The round ligament is to 
be saved and is dissected up from its bed only sufficiently to per- 
mit the operator to raise it up above the aponeurosis of the ex- 
ternal oblique. It is made to lie between this and the fat. All 
sutures should be of fine chromic tendon, and the several fascial 
and muscular layers are brought together by interrupted sutures. 
The skin is closed by a subcuticular suture of silver wire. 



CYSTOTOMY 347 



SUPRAPUBIC CYSTOTOMY 

For several days preceding the operation the bladder should 
be frequently irrigated with borolyptol solution (1 to 32) or with 
an aqueous solution of metallic iodine (1 to £0,000). It is also 
advisable to give urotropin tablets for several days, to render the 
urine antiseptic. The operation is always an elective one except 
to control haemorrhage from the bladder. It is particularly in- 
dicated in the removal of neoplasms and foreign bodies which 
are too large to be extracted through a vesico-vaginal incision or 
through the urethral speculum. A soft, self-retaining catheter is 
introduced and left open just before the operation. 

The patient should be in Trendelenburg's position. The supra- 
pubic transverse curved incision is made. Upon entering the 
prevesical space the loose tissue behind the pubis is separated 
by the fingers until the bladder is exposed. This is caught up 
by tenacula and a transverse incision made into its walls about 
midway between the peritonaeum and the pubis. Care must be 
exercised not to wound the peritonaeum. Xo urine from the 
probably infected bladder should be allowed to escape into the 
prevesical space. After the indicated intravesical operation has 
been performed the bladder wound is closed by fine chromic-ten- 
don interrupted sutures, which sutures do not pass through the 
mucous membrane. If the operator is convinced he has performed 
a technically clean operation he may close the abdominal wound; 
but if the contents of the infected bladder have escaped through 
the vesical incision, the prevesical space should be drained by an 
iodoform-gauze wick introduced at its centre. In the after-treat- 
ment the bladder is kept empty by means of the self-retaining 
catheter, and is washed out once a day with borolyptol (1 to 32). 
In a week's time this catheter can be removed and the patient 
catheterized for some time by the nurse. The wound is usually 
tightly closed in two weeks. 

INFRAPUBIC CYSTOTOMY 

This is employed for the purpose of draining the bladder in 
aggravated cases of cystitis, but chiefly to remove foreign bodies 
from the bladder. So large an incision can be made that stones 
of great size may be crushed and removed. This incision is there- 



348 GYNAECOLOGY 

fore almost always indicated in vesical calculus, while the supra- 
pubic operation is used for removing neoplasms of large size. 

The preparatory treatment is the same as for the suprapubic 
oj)eration. The patient should be in the lithotomy position, lying 
upon her back with abdomen and thighs flexed upon the buttocks 
at the table's edge. A curved male sound is introduced into the 
bladder while an assistant draws down the perinaeum with a short 
Jackson speculum. The sound is made to push the anterior wall 
of the bladder downward, and this protrusion is incised exactly in 
the middle line. After the bladder has been entered the sound is 
pushed into the vagina and is not removed until the operator 
has enlarged the opening into the bladder sufficiently to receive 
his finger. The finger is pressed against the tip of the sound 
and held there, following the sound into the bladder as the latter 
is withdrawn. In this manner the sound acts as a guide into the 
bladder, the flaccid walls of which, even when incised, fold about 
the examining finger. A thorough examination is now made of 
the interior of the bladder, and if the incision already made is 
not long enough, it is enlarged by carefully incising its anterior 
and posterior margins. Any incision into the vesico-vaginal wall 
must be made accurately in the median line. In this way wound- 
ing either ureter is avoided. The anterior limit of the incision 
should stop short of the inter-ureteral fold, and the posterior at 
the point of attachment of the bladder to the uterus. After such 
operation as is indicated has been completed within the bladder 
cavity the incision is to be closed in the same manner as if a 
vesico-vaginal fistula existed, except when the incision is made for 
drainage only, in which instance, of course, the wound is left open. 
If the wound is closed, a self-retaining catheter is introduced and 
the bladder washed out. The bladder is irrigated through this 
catheter for ten days, when the silver-wire sutures 'are removed. 
After that, for a week longer, the bladder is to be emptied by 
catheter every four hours. 

OPERATIONS DURING PREGNANCY 

Unless labour is expected within two months, all lesions of the 
vagina which might cause sepsis after delivery should be cor- 
rected. Therefore, the plastic operations for recto-vaginal and 
vesico-vaginal fistulas and for complete laceration of the peri- 



OPEEATIOXS DTJKIHG PEEGXAXCY 349 

useum should be done. But as a general proposition it may be 
stated that it is advisable to postpone plastic operations until 
after the puerperal month. Abscess of the vulvo-vaginal gland 
likewise always demands removal. 

Adherent Retroposition. — This jeopardizes the life of the foe- 
tus. If a uterus fixed in retroposition becomes impregnated the 
uterus will empty itself as soon as it has risen by enlargement to 
the limit of its bonds. Eeplacement under general narcosis, the 
patient being in the author's position, should be tried, and if it 
be found that the organ cannot be lifted up out of the pelvis, 
posterior vaginal section is indicated so that the adhesions may be 
broken up. The vaginal incision is to be closed. The uterus 
should then be replaced and maintained in a high position for 
some weeks. Laparotomy in such a case is not indicated because 
the operator can do no more than sever the adhesions and dare 
not perform ventrosuspension, and because hernia through the 
abdominal scar is likely to follow the operation, as the enlarging 
uterus forces apart the abdominal parietes. 

Ovarian Cyst. — With this complication the risk is the mother's. 
The cyst should be removed by laparotomy at the seventh month 
of gestation, if it be possible to wait that long, because then the 
abdominal muscles are stretched before the section is made and 
hernia is less likely. If there be evidences of interference with 
the circulation of the cyst, due either to torsion of its pedicle or 
because it is impacted low down in the pelvis, strangulation may 
be expected and the cyst must at once be removed, in the first 
instance by laparotomy, in the latter by vaginal section. Eemoval 
of an ovarian cyst, if done by a skilled surgeon, in no way jeop- 
ardizes the life of the foetus or of the mother. 

Fibroid Tumours. — Both lives are in jeopardy in certain forms. 
If the fibroid is pedunculate it may be jammed against the pelvic 
or abdominal wall by the larger and heavier uterus and a flexure 
in its pedicle be made so acute as to cause gangrene in the tumour, 
but, as a rule, fibroids about the body of the uterus do not inter- 
fere with pregnancy. The same is true of interstitial growths. 
But intraligamentous and retro-peritoneal growths complicating 
pregnancy make an association of conditions of the gravest im- 
port. Xothing can be done in the case of pregnancy with intra- 
ligamentary rlbro-myoma except to wait until the child is viable 
and then perform Cesarean section and extirpate the uterus. 



350 GYNECOLOGY 

When the fibroid is retro-peritoneal it blocks the pelvic outlet, and 
delivery is usually impossible except by Caesarean section. In- 
stead of waiting for the pregnancy to advance to term and then 
performing the elective Caesarean section, I have opened the pos- 
terior cul-de-sac and removed the obstructing fibroids without 
interfering with the pregnancy, the patient going to full term. 1 

No operation is to be considered unless due regard is had for 
the rights of the unborn child. Neither life must be sacrificed 
in hope of saving the other unless death of one is inevitable. 
Fortunately modern gynaecological science is in perfect accord 
with ethical rules in such matters. In" operating upon all 

LESIONS COMPLICATING PREGNANCY THE RULE IS, TO INELICT AS 
LITTLE TRAUMA UPON THE UTERINE MUSCLE AS POSSIBLE, PAR- 
TICULARLY OVER THE PLACENTAL SITE AND ABOUT THE CERVIX. 

The technique employed to remove the various tumours varies 
but little from that described elsewhere. If the growth is to be 
removed by laparotomy the abdominal cavity must be entered 
high enough above the pubis to escape the bladder, which is al- 
ways drawn up in advanced pregnancy. If the pregnancy coexists 
with a sloughing intramural fibroid, or if the patient be septic at 
the time of operation and the sepsis has extended to the uterine 
muscle, total extirpation of the uterus is indicated. 

Cancer of the Uterus. — Women with cancer of the body of 
the uterus are always sterile, and fortunately most of those who 
have cancer of the cervix are also sterile. But cancer of the 
cervix in its beginning, before manifesting itself clinically, is no 
bar to conception. After pregnancy occurs the cancer progresses 
with frightful rapidity. The question then arises, Shall the foetus 
be ignored in the interests of the mother in these early cases, and 
a radical operation be performed? To allow the pregnancy to 
proceed to term dooms the mother either to a Caesarean section 
and ultimate death from cancer or to death from puerperal sepsis 
due to infection by the cancerous cervix. My own practice is to 
treat all cases of early cancer in the pregnant uterus as though 
pregnancy were not present, but in advanced and hopeless cancer 
to let the woman go to term and deliver by Caesarean section. 

An assistant should cleanse by curette and cautery the cancer 
field before the Caesarean section is performed. After the child 

1 H. W. Crouse, The Am. Jour. Obstet., September, 1902. 



RESULTS OF CASTRATION 351 

and placenta are delivered the nterns should be packed with iodo- 
form gauze, one end of which projects through the cervix into the 
vagina, and the uterine wound closed over this. The abdomen 
is then closed. 

Pus Foci. — Suppuration, whether of the adnexa uteri or vermi- 
form appendix, should be treated as though pregnancy did not 
exist. Pregnancy associated with pyosalpinx is exceedingly rare, 
most cases of pelvic suppuration being sterile or aborting early. 

It is important to pay particular attention to the kidney func- 
tion in pregnant cases, for in them the pregnancy puts an addi- 
tional strain upon the kidneys. The specific gravity of the urine 
and the urea percentage must be lowered by hydrotherapy before 
any operation is performed. 

RESULTS OF CASTRATION 

It would be unnecessary to give a description of the local and 
general results of castration were it not for the absurd, often 
brutal, always unkind, statements made by ignorant women and 
practitioners to those who contemplate undergoing, or have sub- 
mitted to operations which necessitate the loss of both ovaries. 
But in order that the student may be fortified against ignorance, 
I will give the results of our observations upon this subject. We 
may consider the results of the radical operation as affecting the 
locality operated upon and as influencing the body at large. 

The most notable result of bilateral oophorectomy is amenor- 
rhea. This is not invariable, but menstruation often persists 
after both ovaries have been removed. It is still more likely 
to disappear if the tubes have at the same time been taken away. 
The younger the woman is, particularly if she has never borne 
children, the greater the probability of amenorrhea appearing. 

It is not positively known why castration sometimes fails to 
produce cessation of menstruation. It is probable that minute 
portions of ovarian tissue have been left in most cases. 

Certain symptoms of the menopause appear, as well as obscure 
nervous phenomena, and the younger the subject the more pro- 
nounced they are. The most prominent are those which relate to 
disturbances in the vaso-motor system. The patient has at times 
attacks of chilly sensations, at others the surface of the body be- 
comes suffused under the influence of a " hot flash." During 



352 GYNAECOLOGY 

these the woman experiences a sense of great embarrassment. 
Many women suffer from a curious lack of mental balance; they 
are easily " rattled/' lose their self-control readily, are unable 
to apply themselves to their duties, and are prone to become intro- 
spective. In others a pathetic melancholia sets in, while a few 
become actually insane. The nearer the patient is to the normal 
menopause, particularly if she has children, the less prominent 
are these symptoms. In young women, the knowledge that they 
are not like other women, that they cannot bear children if mar- 
ried, causes bitter disappointment. All of these symptoms can 
be much increased by mistaken sympathy, or lessened by the 
patient assuming routine duties and leading an outdoor life. I 
have observed that the wives of working men, to whom life is 
real and whose duties are ever present, have, as one woman told 
me, not "time to think about such things." If the uterus and 
tubes are removed and the ovaries left, these disturbances are less 
than when the ovaries alone are sacrificed. Other reasons will 
later be given for conserving the ovaries whenever this be possible. 
On an average, the symptoms of artificial menopause cease within 
a year and a half. To show the rarity of insanity following 
castration, the author has never seen such a result; and only one 
patient became insane after operation, and in her conservatism 
of cystic ovaries was employed. 

Certain local changes occur after castration. The nymphse 
shrink, become glazed and inelastic, the vulva as a whole flattens, 
and the vulval hair thins. The introitus vaginas becomes rigid 
and inelastic. Upon opening the vagina, it will appear of a 
pinkish hue, and its epithelial covering can easily be rubbed off. 
The external genitals have assumed senile appearances. The cer- 
vix uteri will be found shrunken and the vault of the vagina drawn 
in around the cervix. In advanced cases the corpus uteri is found 
much diminished in size. The rigidity of the vulval structures 
often renders coition painful. All of these changes are most 
marked when the operation has been done in nulliparous and 
young women. 

The subject of loss of sexual appetite is one often brought up 
either by patients or their husbands. When a woman has not 
had the sexual desire cultivated she is not apt to acquire it after 
double ovariotomy. If she has fully learned what it is, she does 
not lose it after operation. In many cases where diseased condi- 



RESULTS OF CASTRATION 353 

tions have made of the woman a sexual pervert or nymphomaniac, 
she becomes normal after operation. Occasionally castration, by 
centering a woman's attention upon her special organs, will in- 
crease the sexual desires. Lastly, when coition is painful, due to 
disease, it becomes pleasurable after a cure is effected. 

Certain disturbances in metabolism are produced by castration. 
As a rule the tendency to take on weight is notable. The acqui- 
sition of flesh is general, and unlike the obesity which so often 
sets in at the normal menopause. Women who have lost their 
ovaries maintain a youthful appearance longer than those who 
have not, and the smooth, unwrinkled skin is often a notable 
feature even when the hair is very gray. In a few instances, I 
have seen enormous enlargement of the breasts occur. 

The classical experiments of Curatulo and Tarulli indicate 
the profound nature of these tissue changes. They found that the 
elimination of the nitrogen bears the same relation to the body 
weight as before operation, but that there was a marked diminu- 
tion in the elimination of phosphates. This effect of the ovarian 
function is still more noticeable in cases of osteomalacia in which 
the elimination of phosphates is increased. The results of ovari- 
otomy in these is to reduce the amount of phosphates eliminated 
very markedly. Removal of the ovaries also increases the elimina- 
tion of calcium. The fact is forced upon us that the ovaries 
secrete a substance which powerfully affects metabolism. This 
has been substantiated by the benefits derived from feeding mam- 
mary-gland extract to women who present the symptoms of a 
disagreeable nature during the artificial menopause. 

I have found that alcoholic beverages increase all the sub- 
jective symptoms of the surgical menopause. One of the most 
remarkable results of double ovariotomy is the apparent increase 
in the liability to cancer which it causes. 

There is little influence upon the voice produced by ovariotomy. 
I have performed ablation three times upon noted singers, and they 
all state that their voices have improved since the operation. 



CHAPTER XX 

HuEMOSTASIS 

Bleeding during gynaecological operations, or when due to 
diseases peculiar to women, may be controlled by pressure, by tor- 
sion, by drugs, by electro-haemostasis, by heat, and by ligation. 

Pressure. — If the vessel which has been severed is small it 
may be grasped by artery forceps, which are left on for ten 
minutes while the operation proceeds. Upon removing the for- 
ceps, it will generally be found that the bleeding has ceased. This 
method of stopping haemorrhage — temporary forcipressure — is 
applicable to all vessels of the sixth degree in size and those of 
lesser calibre. Vessels larger than this are better controlled by 
some other method. This temporary forcipressure is particu- 
larly applicable to the vessels severed in median laparotomy and 
in perinaeorrhaphy. As little tissue about the vessel as possible 
should be included in the grasp of the forceps. For this pur- 
pose no forceps is superior to one having the points of the Amer- 
ican bulldog or the Langenbeck pattern. 

The application of pressure in gynaecology has its chief scope 
in the control of parenchymatous haemorrhage. If this occurs 
from the separation of recent lymph effusions during a laparot- 
omy, the bleeding is best controlled by the application of strips 
of mild iodoform gauze. A pressure of not over two ounces in 
degree will suffice to stop such bleeding, and the gauze packing 
is particularly effective if the bleeding surface is caught between 
the gauze and the bony pelvis, an impossible thing, however, when 
the haemorrhage comes from an intestinal wall. It is advisable 
to keep the bleeding surface exposed for some minutes to the 
light and air before applying the gauze packing, as both have 
an influence in causing coagulation of blood. In fact, surfaces 
which very often bleed actively when first separated and which 
seem to demand a pressure-drain to control them, will, upon 
354 



H^EMOSTASIS 355 

being exposed to the light and air for a few minutes, become 
entirely dry. 

During a perineorrhaphy a spouting vessel may be held under 
a piece of iodoform gauze by thumb pressure while the operator 
proceeds with his work, and will often after a few minutes be 
found to have closed. 

Control of bleeding by pressure is particularly applicable 
when it occurs from the uterus. If the cervix is sufficiently open 
the uterine cavity may be packed with iodoform gauze in the same 
manner as is described under curettage. This is particularly 
true when the bleeding is due to the presence of fibromyomata. 
Over such a packing a vaginal tamponade of the same material 
should be placed. Both will need removal in three days. 

If the cervix is closed and the bleeding of sufficient quantity 
to weaken the patient, the uterus should be washed out through 
a Fritsch catheter with two quarts of Thiersch solution to pre- 
vent putrefaction in the after-forming clot. The cervix should 
then be sewed up with silver wire. This can be done without 
narcosis and with but little pain. In three days these sutures 
must be removed, during which time the patient can be subjected 
to treatment to overcome the effects of the previous haemorrhage 
and to prevent its recurrence. The statement is often made that 
this damming up of blood within the uterus will conduce to the 
formation of hematosalpinx and pelvic hematocele. There is 
found, but only occasionally, a condition of retention of blood 
under even greater pressure than is seen in any fibro-myomatous 
case, when the hymen is impervious and no menstrual blood 
escapes. Although the blood is fluid in these cases, there has 
been no observation made of its flowing back through the Fallo- 
pian tubes. The contention is entirely academic and not borne 
out by experience. 

It is next to impossible to pack the vagina with a force suffi- 
cient to control a uterine hemorrhage without at the same time 
interfering with the functions of the bladder and rectum. We 
have all seen cessation of flow follow vaginal tamponade, but it 
was probable that the occurrence was merely coincident. 

Bleeding from cervical growths or ulcerations, which are 
directly under the control of cleansing methods, is amenable to 
forms of treatment not applicable to the interior of the uterus. 
Carcinomatous and other ulcerations in this situation may be 



356 GYNECOLOGY 

subjected to pressure by styptic cotton, by alum-soaked cotton, by 
gauze wet in adrenalin solution, and even to the application of 
the actual cautery. 

Torsion. — Mediate torsion is not employed in gynaecology, 
those vessels which might be so treated being preferably sub- 
jected to occlusion by ligature. Direct torsion is a valuable 
means of closing vessels of the sixth and lesser degrees. The cut 
end of the vessel is grasped in the artery forceps and the forceps 
is turned until the progressive fracture of the arterial coats 
releases the instrument. The vascular walls ruptured in this man- 
ner retract within the lumen of the vessel and effect a speedy and 
sufficient occlusion. The method is particularly valuable in per- 
ineorrhaphy, in which operation it is desirable to avoid as much 
as possible the introduction of ligature material between the 
edges of the wound. 

By Drugs. — Menorrhagia is somewhat lessened by the inter- 
nal administration of tincture of cannabis indica in doses of gtt. 
xv. q. 4 h. This drug also tends to lessen the bleeding from fibro- 
myomata. By far the most powerful influence exercised by any 
drug upon bleeding vessels is by adrenalin. This was first sug- 
gested to me by Dr. Gordon, of Montana. It should be employed 
in a l-to-2,000 solution. A long hypodermic needle is plunged 
directly into the uterine muscle through the cervical tissue, or into 
any presenting part of a tumour, and a few minims of the drug 
are injected. The tissues at once become blanched. Even in per- 
forming hemisection of the highly vascular uterus during either 
abdominal or vaginal hysterectomy, the walls of the uterus along- 
side the proposed line of incision may be rendered bloodless by 
injections of this drug. I have not as yet employed it to control 
the bleeding from the cancerous cervix, but believe it will be par- 
ticularly useful to clear the field of operation for the actual cau- 
tery in such cases. 

The internal administration of large quantities of gelatin for 
some weeks seems to shorten the time of coagulation of the 
blood, and therefore has an indirect haemostatic effect. It is an 
aid in the preparation of an exsanguinated fibroid case for a 
future operation. 

All drugs which slow the heart's action and constrict the arte- 
rioles lessen the amount of blood which will escape from a bleed- 
ing surface; and the vaso-motor dilators have the opposite effect. 



HJEMOSTASIS 



357 



Heat. — Parenchymatous oozing, as from the separated lymph 
planes during a laparotomy, may be checked by the momentary 
application of a sponge dipped in water of about 150° F. But this 
degree of heat also coagulates plasma cells and must therefore 
not be employed against raw surfaces which it is intended to unite 
by suture, such as those made in perinaeorrhaplry, as it would 
interfere with union. Bleeding from a cancerous cervix may be 
checked by the application of the actual cautery. Beyond this, 
ordinary heat is of little value as a haemostatic in gynaecology. 

Electro-haemostasis (Skene's method, Fig. 142).— Next to the 
control of severed vessels by ligatures this is the most valuable 




Fig. 142. — Treatment of Pedicle of Ovarian Cyst. (Diagrammatic.) 



means at our disposal for preventing bleeding. It has a utility 
little appreciated by surgeons. It is singularly applicable to the 
control of large vessels in the pedicles of pedunculate fibro-myo- 
mata and ovarian tumours. 



358 GYNECOLOGY 

The tumour is withdrawn from the abdomen or through the 
vaginal incision and its pedicle grasped with the clamp (Fig. 142), 
which is closed tightly enough to control its vessels, and the 
tumour cut away. Beneath the clamp either a non-conducting 
shield or sufficient wet gauze pads are introduced to prevent burn- 
ing the tissues beneath the clamp. It is well to grease the blades 
of the clamp with sterilized vaseline before applying it in order 
to prevent its sticking to the tissues after the clamp has been 
used. At first the forceps is closed to the first catch, then the 
current is turned on for from a half to one minute. The forceps 
is then clamped down hard and the current left on for a total 
of three minutes. The forceps is then removed and the stump 
will be found to be a thin, corrugated, translucent, and homo- 
geneous structure in which neither vessels nor other tissue can 
be recognised. The time during which the current is on will 
depend upon the thickness of the pedicle. When the tissues adja- 
cent to the pedicle bubble and turn gray the process is nearly com- 
plete, and is complete when the bubbling ceases. The tissues 
must not be burned. The degree of heat to be developed is 
about 192° F. The vessels become agglutinated and the individual 
component parts of the stump are lost in the dehydrated pedicle. 
An absolutely sterile pedicle is produced and ligatures are 
unnecessary. The reader is referred to Dr. Skene's book for 
elaboration of the details of this most valuable addition to our 
technique. It has been used by me in the treatment of ovarian 
pedicles, ectopic sacs, and chronic salpingitis, through the vagina. 
I have never seen a secondary bleeding occur after it. 

Angeiotripsy. — This is the application of a crushing force to 
the vessels by means of a poAverful forceps, some of which are 
capable of effecting a pressure of 3,000 pounds. The forceps 
is left on each stump for two minutes and then removed. The 
pedicle will be found thinned and exsanguinated. Secondary 
haemorrhage occurs with disagreeable frequency after the use of 
this instrument, and some of its early advocates now merely 
employ it to thin out the pedicle before applying ligatures. This 
method of hsemostasis never became very popular and is fortu- 
nately less so than at first. 

Ligation. — In Continuity. — Obliteration of the lumen of a 
vessel is accompanied most often by the formation of a clot, but 
not infrequently no clot forms and the vessel closes by union 



ELEMOSTASIS 



359 



between the internal coats, which are held in apposition by the 
ligature. At one time it was thought necessary to apply suffi- 
cient force in tying the vessel to rupture the intima and perhaps 
break the inner portion of the media. But the classical experi- 




Fig. 143. — Chromic Catgut Ligature after Three Days' Application Around the 

Carotid ( x 60). 
The intestinal villi of this gut are well seen. This mucous tissue in the ligature material 

is objectionable in that it renders sterilization difhcult and weakens the ligature. 

The fissure allows of the too early penetration of the corpuscles. (Ballance and 

Edmunds.) 

ments of Prof. John A. Wyeth have shown that all that is needed 
is to secure a close apposition between the inner walls of the ves- 
sel. Deligated vessels do not always remain closed, but the blood- 
current may become established either wholly or partially after 
the lapse of some months or years. The obliteration of a vascu- 




Fig. 144. — Chromic Catgut after Fourteen Days' Application Around the 
Carotid ( x 30). 
Suppuration occurred and the catgut is being rapidly broken down, cells being every- 
where in its structUx'e. 



lar trunk is more surely permanent if it be severed between two 
ligatures, for not only will the closure be effected by union 
between the intima walls, but also by the formation of scar tissue 
at the cut ends of the vessel. If sufficient force be employed in 
tying the ligature to rupture any of the coats of the vessel it is 
23 



360 



GYNECOLOGY 



weakened by just that much, and secondary haemorrhage is more 
likely in case infection occurs. 







Fig. 145. — Ordinary Silk after Forty-two Days Around the Carotid ( x 90). 

The drawing shows the structure of the silk and the invasion of the upper portion by 

leucocytes. (Ballance and Edmunds.) 




Fig. 146. — Silkworm Gut after Twenty-one Days Around the Carotid ( x 200). 

Corpuscles have collected but have not penetrated. The striations in the ligature were 

produced by the section knife. (Ballance and Edmunds.) 

The force, then, must be just sufficient to approximate 
the intima. Therefore an inelastic ligature material must be 



H^MOSTASIS 



361 




used, for a contracting ligature continues to close down after the 
knot is tied. 

Obliteration by union begins within a few hours after the 
vessel is tied, but it takes some days for the occlusion to become 
firm. Therefore the ligature must maintain its position and shape 
for not less than a week, and it is 
advisable that in tying large vessels 
like the iliaes, a ligature be used 
which will hold for two weeks or 
over. To do this the ligature must 
not stretch as it softens in the fluids 
of the tissues, and it should be of so 
homogeneous a structure that leuco- 
cytes can with difficulty penetrate 
into it. This element of homoge- 
neity is additionally valuable in case 
infection occurs, for the denser and 
more homogeneous the structure of 

the ligature the more difficult is it to infect it. It is, however, 
desirable to have the ligature disappear at some time, otherwise 
it will act as a foreign body. The requirements of a perfect 
ligature material are met by chromic kangaroo tendon. 



Fig. 147. — Kangaroo Texdox after 
Ttventy-oxe Days Around the 
Carotid ( x 20). 

A mass of corpuscles is seen cover- 
ing the ligature, but the invasion 
is upon the surface only. (Bal- 
lance and Edmunds.) 





Homogeneitv. 


Elasticity. 


Susceptibility 
to infection.' 


Sterilization. 


Absorba- 
bility. 


Catgut, chromic. 


Many differ- 


Marked 


Very sreat. 


Most 


Irregular 




ent layers 






difficult. 


and unre- 




of tissue. 








liable. 


Kangaroo tendon. 


Absolute. 


Xone. 


Very slight. 


Easv. 


Constant 


chromic. 










and uni- 
form. 


Silk. 


Xone. 


Slight. 


Very great. 


Easy. 


After a 

great many 

Years. 


Silkworm gut. 


Absolute. 


Xone. 


Very slight. 


Easv. 


Xone. 


Silver wire. 


Absolute. 


Xone. 


Xone. 


Easy. 


Xone. 



The I- not which must be employed is of great importance. 
The one most easily tied is the reef knot (Fig. 148). But one 
twist, not two, of the ends should be taken in forming the first 
part of the knot, and the second should be made without lifting 
the vessel. It is impossible to prevent a very slight slipping in 
the first knot as the second is tied; and this slipping is increased 



362 



GYNECOLOGY 




Fig. 148.— The Eeef Knot. 



if the first knot be made by two turns and if the second knot 
is made while making traction on the ends. As the first knot is 
made it should be held for a few moments so that the tissues 

may lose some of their elasticity. The 
second knot is then quickly but gen- 
tly made. I generally put in a third 
knot. An absolute preventive against 
slipping is the " stay knot " (Fig. 
149). With this two ligatures are used side by side and the first 
knot in each is made separately. The ends of both are then used 
to make the second knot. The degree of force necessary to secure 
an occlusion of the vessel should be accurately determined by 
practice with a scales. This is important when the subject of 
ligating such vessels as the internal iliacs, or the uterines in 
massive fibromata, is contemplated. Two pounds' pressure will 
close the iliac, six pounds will produce a superficial rupture, while 
eight pounds will rupture two coats of the vessel. In using two 
ligatures to form the stay knot, a method necessary with the 





Fig. 



149. — The First Part of the 
Stay Knot. 



Fig. 150.— The Finished 
Stat Knot. 



largest vessels only, the index fingers are under great strain if a 
force of ten pounds is applied in tying the knot. 

The uterine artery has a very dense outer coat, it being as 
thick as the media, and thicker than the externa of the internal 
iliac. Therefore a comparatively greater force is needed to 
occlude it, and it will easily stand a pressure of three pounds 
without danger. It is interesting to know that the uterine artery 
in the virgin is larger than in the woman at term. 

En masse. — The ligature is thrown around all the tissue about 
the vessels and no attempt is made to isolate them. As a result 
there is much shrinkage of the soft parts within the grasp of the 
loop and the ligature becomes loose, inviting haemorrhage. This 



H^EMOSTASIS 363 

danger the operator guards against by employing a force which 
makes his ligature crush the tissues down about the vessel. Mass 
ligatures are admissible only when applied to soft pedicles like 
the ovarian or the round ligament whose artery is small. But 
the uterine artery should never be secured in this manner. 

Haemostasis by Forceps. — This method of causing obliteration 
of vessels is employed in laparotomy only when removing the 
uterus, ovaries, and tubes for virulent streptococcus puerperal in- 
fection. 

In such cases time is a most important element, and inasmuch 
as an abdominal drain of iodoform gauze must be used on account 
of the retroperitoneal lymphatic infection, the slough produced 
by the forceps will be taken care of by the drain. In such cases 
the forceps are indicated, because there is no known ligature 
which will not become infected. But once in his experience 
lias the author been compelled to perform such an operation, 
fortunately with success, and the indication must be exceeding- 
ly rare. 

It is in the performance of vaginal hysterectomy that this 
method of controlling the vessels finds its chief application. 
The forceps are, as has been described in the article upon this 
operation, left on for forty-eight hours, when they are removed. 
The result of the forcipressure is to produce slough in all the 
tissues which have been subjected to it. This slough is cast 
off in the second or third week, long after the vessels have 
become completely obliterated. The sloughs putrefy and their 
formation is accompanied by a very disagreeable odour, which, 
however, is not detected if the wound is dressed every three days. 
Inasmuch as the sloughs are strictly extraperitoneal, the stumps 
being in the vagina, no infection results from their formation. 
It is in pus cases that this method of operating is chiefly indi- 
cated, for it renders the operation speedy and safe, and avoids the 
application of ligatures in a pus field, which are so apt to become 
infected and produce future mischief. In removing fibroid uteri 
between forceps, after the operation is completed, if it is desirable 
to do so, ligatures can be substituted for the forceps. At no 
point in the convalescence should the operator pull upon the 
sloughs to dislodge them if they are tightly fastened, because 
doing so may produce bleeding. 



CHAPTEE XXI 
ANOMALIES 

General. — Total absence of all the organs of generation, both 
internal and external, is unknown, careful examination having 
shown rudimentary traces in all suspected cases. 

A more common association of abnormalities is the blending 
of the male and female types, producing hermaphroditism. These 
may be classified as — 

1. Bilateral, where the ovaries and testicles exist upon both 
sides, and of which there is no known case. 

2. Unilateral, where an ovary and testicle exists upon one 
side, the existence of which is denied by many. 

3. Lateral, where an ovary and testicle are present upon 
opposite sides. 

The nearest approach to true bilateral hermaphroditism known 
was the noted case of Eokitansky upon which an autopsy was 
held. There two ovaries, two tubes, rudimentary uterus, and one 
testicle with a vas deferens containing spermatozoa were found. 
There was externally an imperforate penis and bifid scrotum. 

The tendency of most cases is towards the male type. There 
is generally a rudimentary penis, often interpreted as a hyper- 
trophied clitoris. There is complete hypospadias, the scrotum 
being bifid. One or both testicles may not have descended. As a 
rule there is more or less hair on the face, the shoulders are 
square, the mammae absent, and the voice like that of a boy. 
These pseudo-hermaphrodites are not uncommon. 

Treatment. — These radical errors in development are interest- 
ing to the scientist rather than to the practical surgeon. They 
very rarely call for operative treatment. Most pseudo-hermaphro- 
dites are men reared and dressed as women. Some even marry 
as women, as did a case under my charge. In such an instance 
there can be little reason for deepening by operation the perineo- 
scrotal fissure merely for purposes of copulation, as most subjects 
364 



ANOMALIES 



365 



use the urethra or rectum for that purpose. Nor should the 
penis be amputated. The true indication for treatment is found 




Fig. 151. — Pseudo-Hermaphrodish Proper. 

External genitals of Jolie D (man) ; &, frsenuui ; mm, meatus ; or, vulvar orifice. 

The case is one of perineo-scrotal hypospadias. (Pozzi.) 

in the necessity for releasing the penis, and by plastic work cor- 
recting- the hypospadias. 



SPECIAL 

Vulva. — The clitoris, nympha?, and labia may be absent. The 
labia and nymphse may be multiplied. Enormous hypertrophy 
of either one or all these structures may exist. The clitoris may 
be bifid, constituting epispadias; or the posterior wall of the 
urethra may be lacking, forming a hypospadias. 

Hymen. — The hymen may be imperforate, the condition being 
usually acquired, rarely congenital. The hymen may have mul- 
tiple openings or be entirely absent. It is subject to great varia- 
tions in form and shape. 

Vagina. — The vagina may be congenitally absent, in which 
case the uterus also is absent; or it may become obliterated in 



366 



GYNECOLOGY 



early life. Atresia of the vagina is not very uncommon, a fibro- 
muscular cord closing the canal at some point. When menstru- 
ation begins, the blood is retained, constituting a hsematocolpos. 
If the occlusion is near the vulva it can readily be overcome; but 
if situated high up and the lower part of the tube is obliterated 
careful dissection is needed to correct the deformity. Whenever 
such an accumulation is evacuated the canal should be kept 




Fig. 152. — Old Atresia of the Vagina opened and evacuated ; Interrupted Su- 
tures in Place to draw the Vaginal Mucosa down to the Mucosa at the 
Vaginal Outlet, bridging over the Denuded Area in the Connective Tissue. 



scrupulously clean, and any new channel which has been made is 
to be kept open by Sims's glass plug while healing is going on. 

The general scheme of suturing, when this is possible, is shown 
in the illustration. 

Double Vagina. — This may be either complete throughout the 
entire length of the tube, or for only a portion, a ridge extending 
down the middle of the vagina dividing it into two lateral chan- 
nels. The condition is frequently found to coexist with a septate 



ANOMALIES 



367 



uterus. The saeptum can be safely incised and with little bleeding, 
the anterior and posterior raw surfaces being separately closed 




Fig. 153. — Double Vagina with a Thick Fleshy Sjeptum. The Left Orifice is 
Oval, while the Eight is Crescentic. 

by running sutures and kept apart by iodoform dressing to pre- 
vent their reuniting. 

The Uterus. — The lower portions of the ducts of Miiller be- 
come fused into a single canal about the tenth week of foetal life, 
and the upper portion of this canal becomes the uterus, while 




Fig. 154. — Uterus Septus. (Gravel.) 

its lower portion forms the vagina. Errors in this fusion will 
produce various malformations of the uterus. 



368 



GYNECOLOGY 



The uterine cavity may be divided by a sseptum coming down 
from the fundus, but the cervix be single, forming a uterus sceptus. 

When the fundus is bifid and the cervix single, the case is one 
of uterus bicornis. 




Fig. 155. — Bicorn Uterus with Single Neck. (Kussmaul.) 

If the division be complete, there being two separate organs, 
it is a case of uterus didelphys (Fig. 156). 




Fig. 156. — Didelphic Uterus and Divided Vagina. 
a, right segment ; 6, left segment ; c, d, right ovary and round ligament ; /, e, left ovary 
and round ligament ; fc, vaginal sseptum ; h, i, right cervix and vagina ; gr, j, left 
cervix and vagina. (Oliver.) 

The uterus may be rudimentary, there being merely a fibrous 
cord to represent it, or may retain an infantile form, constituting 
uterus fcetalis. 



ANOMALIES 369 

Treatment. — Anomalies of the uterus call for no treatment. 
Their types should be borne in mind as presenting complications 
during gynaecological operations. The author once was compelled 
to curette one horn of a uterus sseptus after it had aborted, another 
physician having failed to discover its presence while removing a 
dead foetus from the other horn. Conception in one-half of a 
uterus sseptus will arouse a suspicion of interstitial ectopic preg- 
nancy, and it is probable that many of the cases reported as inter- 
stitial pregnancies were in reality conceptions in a uterus saeptus. 

The several anomalies of the uterus produce no symptoms 
which call for operation, and are interesting from an obstetrical 
standpoint chiefly. 



CHAPTER XXII 
INSTRUMENTS 




Fig. 157. — The Operating Table folded for Shipment. 




Fig. 158. — The Operating Table set up and in 
Trendelenburg's Position. 
370 



INSTRUMENTS 



371 




Fig. 159. 



The Author's Hysterectomy Clamps with Detachable Handles. 




Fi&. 160. 
SO, Situs's speculum ; 31 and 32, Jackson's retractors 



S3, Pean's lateral 



retractor: 3L 



Pryor's lateral retractor; 35, Pryor's grooved retractor; 36, Pryor's rectal tube ; 38 

lammaria tent ; 39, Pean> anterior retractor; #, ^ #, U , Fritsch-Bozeman double 
irrigating tubes; 40, Sims's glass plug; 47, Pryor-Pean trowel; 45, urethral specu- 
lum ; 46, Pryor's pessary ; 48, Munde's curette ; 49, Sims's curette. 



372 



GYNAECOLOGY 



a. 




INSTRUMENTS 



373 




374 



GYNECOLOGY 





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INDEX 



Abdomen, auscultation of, 3. 
examination of. 1. 
inspection of, 1. 
palpation of, 3. 
percussion of, 3. 
Abdominal hysterectomy for cancer, 
322. 
for fibroids. 247. 
for pus, 304. 
myomectomy, 244. 
ovariotomy, 264. 

section, closure of wound after, 
234. 
conservative operations in, 274. 
curved transverse, 237. 
in ectopic gestation, 268. 
lateral, 236. 
management of patients after, 

28S. 
median. 232. 

preparation of patient for, 231. 
sinus. 114. 
Ablation. See Hysterectomy. 
Abortion, tubal, 152. 
Abscess of broad ligament, 66. 
Abscess of vulvo-vaginal gland, 16. 
Accidents in vaginal section, 318. 
Adeno-carcinoma of cervix, 172, 177. 
Adrenalin, 356. 

Advanced cancer, treatment of, 339. 
Alexander's operation, 223. 
Amenorrhoea, 23, 34, 142. 
Amputation of cervix, 199, 203, 337. 
Angeiotripsy, 358. 
Anomalies, 264. 
Anteflexion, 73. 
Anterior vaginal incision, 242. 
Anteversion. 73. 
Appendicitis, 318. 
Atresia of vagina. 366. 
Author's instruments, 370. 
position. 7. 12. 
treatment, 30. 
24 



Bartholinitis, 16. 
Bilateral incision of cervix, 196. 
Bimanual reposition, 80. 
Bivalve speculum, 10. 
Bladder, calculus in, 133. 

carcinoma of, 126. 

contraction of, 122. 

descent of, 97. 

incision of, 347. 

inflammation of, 122. 

inspection of, 128. 

papilloma of, 125. 

tuberculosis of 130. 

tumours of 125. 
Bloodletting. 20. 
Broad-ligament abscess, 66. 
cyst, 136. 206. 
fibroid, 157, 252. 
pregnancy. 149, £70. 

Calculus, ovarian, 64. 

ureteral, 134. 

vesical. 133. 
Cancer and pregnancy. 181. 
Cancer of body of uterus, 181. 

diagnosis, 184. 

symptoms, 1S3. 

treatment, 184. 
Cancer of cervix, 171. 

diagnosis. 179. 

prognosis, 181. 

symptoms, 175. 

treatment. 181, 339, 350, 326, 337. 
Cancer of cervix uteri, 171. 
Cancer of urethra, 120. 
Cancer of uterus, 170. 

causes. 170. 
Cardiac disease and endometritis, 23. 
Castration, results of 351. 
Cervix, amputation of, 199, 203, 337. 

cancer of. 171. 

dilatation of. 191. 

fibroid of. 167. 



376 



GYNECOLOGY 



Cervix, hypertrophy of, 77, 106. 

incision of, 196. 

inflammation of, 20. 

laceration of, 178. 

sarcoma of, 187. 
Cceliotomy. See Abdominal Sec- 
tion. 
Colpo-perinseorrhaphy, 206. 
Colporrhaphy, 220. 
Complications after vaginal hysterec- 
tomy, 318. 
Conservative operations upon ad- 

nexa, 271, 274, 277. 
Curettage in fibromyoma, 169. 

indications for, 199. 

of uterus, 191. 

operation, 192. 
Cyst of the corpus luteum, 146. 

of the ovary, 138. 
Cystotomy, 347. 
Cystoscopy, 128. 

Deciduoma malignum, 187. 
Dermoid cyst of the ovary, 141. 
Diffuse suppuration, 59, 68. 
Dilatation of the cervix, 189. 
Diseases of urethra and bladder, 116. 
Diseases of the vulva, 100. 
Distortions and displacements, 70. 
Dorsal position, 4, 8, 10. 
Drainage after cceliotomy, 300, 321. 
Drainage after vaginal hysterectomy, 

321. 
Dudley's operation in anteflexion, 

198. 
Dysmenorrhea, 38, 56, 75, 160. 

Ectopic gestation, 148. 

abdominal section in, 268. 

aetiology, 151. 

classification, 149. 

conservative operations, 276, 278. 

diagnosis, 154. 

examination in, 153. 

symptoms, 151. 

treatment, 154. 

vaginal section in, 270. 
Electricity in fibromyoma, 168. 
Emmet's operation, 211. 
Endoeervicitis, 20. 
Endometritis, 22. 
chronic, 25. 
gonorrhceal, 24. 



Endometritis, hsematogenous, 23. 
hypertrophic, 159. 
puerperal, 28. 
putrid, 32. 
septic, 26. 
Epithelioma of cervix, 171. 
Erosion of cervix, 20, 178. 
Examination of patient, 1. 
abdominal, 1. 
by instruments, 9. 
combined method, 5, 12. 
pelvic, 4. 
rectal, 8. 
Exploratory abdominal section, 52. 
vaginal section, 52. 

Faecal fistula, 115. 
Fallopian tubes, abscess of, 59. 
cysts of, 57. 
gonorrhoea of, 50, 54. 
inflammations of, 50. 
sepsis of, 53, 54. 
tuberculosis of, 58. 
False membrane in uterus, 29. 

on vagina, 27. 
Fibroma of ovary, 148. 
Fibromyoma of uterus, 156, 349. 
classification, 157. 
degeneration in, 156. 
diagnosis, 164. 
examination in, 163. 
prognosis, 167. 
symptoms, 160. 
treatment, 168, 247, 283, 345. 
Fistula, abdominal, 114. 
faecal, 114. 
inter visceral. 113. 
recto-vaginal, 113. 
uretero- vaginal, 111. 
urethral, 113. 
vesico-vaginal, 109. 
Folliculitis, cervical, 20, 179. 

Gonorrhoea. (See the several or- 
gans.) 
Gout and endometritis. 23. 
Graafian follicle cyst, 146. 

Haematocele, intraperitoneal, 153. 
Haematoma of ovary, 64. 
Haematosalpinx, 150, 153. 
Ha?mostasis, 354-363. 

in vaginal hysterectomy, 321. 



INDEX 



377 



Heat as a haemostatic, 357. 
Hemisection, 311. 
Hermaphroditism, 364. 
Hernia after laparotomy, 322. 
femoral, 345. 
inguinal, 346. 
median ventral, 342. 
umbilical, 345. 
History, taking the, 1. 
Hydatid of Morgagni, 138. 
Hydrocele of round ligament, 138. 
Hydrops folliculi, 275. 
Hydrosalpinx, 50, 54, 57, 275, 278, 

283. 
Hymen, anomalies of, 365. 
Hyperinvolution, 37. 
Hypertrophy of cervix, 77, 106. 
Hypodermoclysis, 303. 
Hysterectomy, abdominal, for can- 
cer, 322. 
for fibroids, 247. 
for pus, 304. 
vaginal, for cancer, 328. 
for complete prolapse, 323. 
for fibroid, 259. 
for pus, 306. 
Hysterocystorrhaphy, 222. 

Ileus, 296. 

Incision, abdominal, 232. 

of cervix, 196. 

Kelly's, 132. 

Langenbeck's, 132, 236. 

vaginal, 238, 242. 
Inflammation of cervix, 19. 

of ovaries, 62. 

of peritonaeum, 38. 

of tubes, 50. 

of ureter, 126. 

of urethra, 116. 

of uterus, 22. 

of vagina, 17. 

of vulva, 14. 
Infrapubic cystotomy, 347. 
Infusion, 301. 
Instruments, 369. 
Intraligamentary abscess, 67. 
.cyst, 136, 266. 

fibroid, 157, 252. 

pregnancy, 149, 270. 
Intra-uterine growths, 246. 
Inversion of the uterus, 90. 
Irrigation of uterus, 26, 193. 



Jackson's speculum, 11. 

Knee-chest position, 8, 12, 82. 
Knot, choice of, 362. 

Laceration of the cervix, 92, 178. 

perinaeum, 95, 98. 
Langenbeck's incision, 236. 
Laparotomy. See Abdominal Sec- 
tion. 
Latent gonorrhoea, 50. 
Lateral abdominal incision, 236. 
Latero-version, 92. 
Leucorrhcea, 20, 23, 24, 27, 34, 37, 77, 

175, ls3. 
Ligation en masse, 362. 

of internal iliac arteries, 334. 

of uterine arteries, 169. 

of vessels, 258. 
Ligatures, choice of, 361. 
Lithotomy position, 6. 
Lymphangeitis, 28. 

]\ Falaria and endometritis, 23. 
Mammary-gland extract, 26, 168. 
Management of patient after cceliot- 

omy, 288. 
Mann's operation for retroversion, 

221. 
Median abdominal incision, 232. 
Menorrhagia, 160. 
Method, Brandt's, 12. 

combined. 12. 

Pryor's, 30. 

Sims's, 6, 11. 
Metritis, 35. 
Metrorrhagia, 160, 175. 
Morcellation. abdominal, 232. 

vaginal, 260, 316. 
Morgagni, hydatid of, 138. 
Myoma uteri, 156. 
Myomectomy, abdominal, 244. 

vaginal, 245. 
Myometritis, 35. 
Myxomatous peritonitis, 46. 

Nephritis, 299. 

Operations during pregnancy, 348. 
Ovariotomy, abdominal, 264, 349. 

vaginal, 267. 
Ovaritis or oophoritis, acute, 29, 62, 
279. 



378 



GYNECOLOGY 



Ovaritis or oophoritis, cedematous, 

63. 
Ovary, abscess of, 63, 64, 65, 275. 

apoplexy of, 62. 

atrophied, 64. 

calculus in, 64. 

congested, 13. 

cyst of Graafian follicle of, 146. 

cystic, 64, 65, 275. 

dermoid cyst of, 141. 

fibroid of, 148, 267. 

glandular cyst of, 138, 349. 

haematoma of, 62, 64, 65. 

papillomatous cyst of, 139. 

parovarian cyst of, 136. 

pregnancy in, 150. 

prolapsed, 13. 

proliferating cyst of, 138, 264, 349. 

sarcoma of, 182, 267. 

sclerosis of, 63, 65. 

tuberculosis of, 65. 

Pachysalpingitis, 51. 
Packing the uterus, 194. 
Palpation of abdomen, 3. 
Papillomatous cyst, 139. 
Parotitis and ovaritis, 63. 
Parovarian cyst, 136. 
Pelvic examination, 4. 

lymphangeitis, 28. 

suppuration, 281. 
Percussion of abdcmen, 3. 
Perinseorrhaphy, 205. 
Perioophoritis, 62. 
Peritonitis, causes, 38. 

diagnosis, 42. 

myxomatous, 46. 

prognosis, 43. 

septic, 293. 

symptoms, 39. 

treatment, 43, 279. 

tubercular, 46. 
Pessary, 83. 

Phthisis and endometritis, 23. 
Plan of history, 2. 
Plasmodia and endometritis, 23. 
Pleurisy, 299. 
Pneumonia, 299. 
Polypi, 21, 119. 
Position, author's, 7, 12. 

dorsal, 4, 10. 

knee-chest, 8, 12. 

lithotomy, 6. 



Position, Sims's, 6, 11. 

Trendelenburg's, 4, 7, 10. 
Pregnancy and cancer, 181. 

operations during, 348. 
Preparation of patient for operation, 

230. 
Pressure as a haemostatic, 354. 
Prolapse of ovary, 277. 

of uterus, 86, 323. 
Pruritus vulvae, 17. 
Pseudo-hermaphroditism, 365. 
Puerperal sepsis, 30. 
Putrid endometritis, 32. 
Pyogenic membrane, 59. 
Pyometra, 34, 174. 
Pyosalpinx, 50, 60. 

Rectal examination, 8. 
Rectocele, 97. 
Recto-vaginal fistula, 113. 
Reef knot, 362. 
Relation of ureters, 308. 
Relative merits of abdominal and vag- 
inal section in pus cases, 319. 
Replacement, bimanual, 80. 

in knee-chest position, 82. 

by repositor, 82. 

by sound, 82. 
Results of castration, 351. 
Retroposition, adherent, 85, 227, 345. 

movable, 82. 
Retroversion, Alexander's operation 
for, 223. 

and retroflexion, 78. 

author's operation for, 227. 

hysterocystorrhaphy, 222. 

Mann's operation for, 220. 

pessary in, 83. 

ventro-suspension for, 221. 
Round ligament, hydrocele of, 138. 

Salpingitis, acute gonorrhceal, 50. 

causes, 50. 

diagnosis, 52. 

sequelae, 53. 

symptoms, 51. 

treatment, 52. 
Salpingitis, chronic gonorrhceal, 54. 

treatment, 56. 
Salpingitis, septic, 53, 54, 279. 

causes, 53. 

sequelae, 54. 

symptoms, 53. 



INDEX 



379 



Salpingitis, septic, treatment, 54. 
Salpingitis, tubercular, 58. 
symptoms, 59. 
treatment, 59. 
Salpingo-oophorectomy, 282. 
Bovee's method, 284. 
in ovarian abscess, 284. 
in pyosalpinXj 284. 
for retention cyst, 283. 
normal, 283. 
Salpingostomy, 276. 
Saprsemia. See Putrid Endome- 
tritis. 
Sarcoma of cervix, 18G. 
Sarcoma of ovary, 186. 
Sarcoma of uterus, 184. 
symptoms, 185. 
treatment, 186. 
Sclerosis of ovaries, 63. 

tubes, 51. 
Secondary haemorrhage, 291, 324. 
Sensitive vulva, 4. 
Sepsis after operation, 292. 
Septicaemia, 30. 
causes, 29. 
diagnosis, 30. 
mortality, 30. 
sequela?, 30. 
symptoms, 30. 
treatment, 30. 
Septic endocervicitis, 20. 
Shock, 299. 

Sims's operation on cervix, 197. 
position, 6, 11. 
speculum, use of, 11. 
Skene's method of haemostasis, 357. 
Stay knot, 362. 
Sterility, 38, 76, 196, 198. 
Stoltz's operation, 219. 
Subcuticular suture, 234. 
Subinvolution, 37. 
Suburethral abscess, 117, 118. 
Suppression of urine, 298. 
Suppuration, pelvic, 59, 68, 351. 
Suprapubic cystotomy, 134, 347. 
Syphilis, 23, 179. 

Tactus eruditus, 5. 
Thrombophlebitis, 28. 
Thyreoid extract, 168. 
Tonsilitis, 300. 
Torsion of vessels, 356. 
Trachelorrhaphy, 202. 



Trendelenburg's position, 4, 7, 10. 
Tubal abortion, 152. 
Tuberculosis of the bladder, 130. 

cervix, 108. 

corpus uteri, 34, 179. 

ovaries, 65. 

peritonaeum, 46. 

tubes, 58. 

ureter, 132. 
Tubo-ovarian cyst, 57. 

Ureter, catheterization of, 130. 

stricture of, 128. 

tuberculosis of, 132. 
Ureteral calculus, 134. 
Ureteritis, acute, 126. 

chronic, 127. 
Uretero-vaginal fistula, 111. 
Ureters, position of, in vaginal hys- 
terectomy, 308. 

relations of, 308. 
Urethra, cancer of, 120. 

dilatation of, 121. 
Urethral caruncle, 118. 

condyloma, 119. 

cyst,* 119. 

fistula, 113. 

polypi. 119. 

stricture, 121. 
Urethritis, 116. 
Urethrocele, 119. 
Uterus, anomalies of, 367. 

anteflexion, 73. 

anteflexion with retroversion, 76. 

anteversion of, 73. 

cancer of, 170. 

cancer of body of, 181. 

cancer of cervix of, 171. 

deciduoma malignum, 187. 

distortions and displacements, 70. 

fibromyoma of. 156. 

hyperinvolution, 37. 

inflammations of cervix, 19. 

inflammations of endometrium, 
22. 

inflammations of muscularis, 35. 

inversion of, 90. 

lacerations of cervix, 92. 

prolapse of, 86. 

replacement of, 80. 

retroversion and retroflexion, 78. 

sarcoma of, 184. 

subinvolution of, 37. 



380 



GYNAECOLOGY 



Vagina, anomalies of, 365. 
atresia of, 366. 
condylomata of, 105. 
diseases of, 104. 
double, 366. 
tuberculosis of, 105. 
Vaginal ablation in complete pro- 
lapse, 323. 

conservative operations in, 277. 

for pus, 306. 

of fibroid uterus, 259. 
cystotomy, 134. 
cysts, 104. 

in ectopic gestation, 270. 
hysterectomy for cancer, 328. 
myomectomy, 245. 
ovariotomy, 267. 
section, 238. 

anterior, 242. 

posterior, 238. 
Vaginitis, 17. 
adhesive, 18. 
emphysematous, 18. 
gonorrhceal, 18. 
granular, 17. 



Vaginitis, senile, 18, 105. 

treatment, 18. 
Vaginismus, 75, 108. 
Vagino-intestinal fistula, 115. 
Varicocele, 148. 
Ventral fixation, 221. 
Vesical calculus, 133. 
Vesico-vaginal fistula, 109. 
Vulva, anomalies of, 365. 

carcinoma of, 103. 

condylomata of, 101. 

diseases of, 100. 

elephantiasis of, 100. 

hsematoma of, 101. 

hydrocele of, 102. 

kraurosis of, 102. 

papillomata of, 101. 

tuberculosis of, 103. 
Vulvitis, follicular, 14. 

gonorrhceal, 14. 

simple, 14. 

spread of, 15. 

treatment, 15. 
Vulvo- vaginal cyst, 100. 

gland, abscess of, 16. 



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English is an event of importance. The book has been written especially to meet the 
needs of the general practitioner, but by reason of an exhaustive treatment of physio- 
logico-chemical processes and a clear and concise review of laboratory methods, it will 
prove of value both to students and to all sorts and conditions of medical men." — Jour- 
nal of Medicine and Science, Portland, Me. 

" The popularity of Dr. Boas's treatise in German, and the absence of any exhaustive 
work on intestinal diseases in English, have led to this translation. Adapted to meet 
the needs of the general practitioner, but of exceptional value to other scientific investi- 
gators on account of its thorough and concise description of physiologico-chemical 
processes and laboratory methods. This elaborate edition contains added material in 
the chapters on Appendicitis and Hydrotherapeutics. A special account is given of the 
intestinal gases. Internal medicine owes a heavy debt to surgery, for the surgeon has 
contributed most to the progress reflected in this book. This is notably true of our 
knowledge of appendicitis, intestinal obstruction and stenosis, benign and malignant 
tumors. The invaluable contributions the American profession is universally conceded 
to have made are utilized and acknowledged throughout by numerous references." — 
Indiana Medical Journal. 

D. APPLETON AND COMPANY, NEW YORK 



TEXT-BOOK 
OF OPHTHALMOLOGY. 

By De. ERNEST FUCHS, 

PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF VIENNA. 



SECOND AMERICAN EDITION, REVISED AND ENLARGED, 
FROM THE SEVENTH ENLARGED AND IMPROVED GERMAN EDITION, 

By A. DUANE, M. D., 

ASSISTANT SURGEON, OPHTHALMIC AND AURAL INSTITUTE, NEW YORK. 

With Two Hundred and Twenty-seven Illustrations, and an Appendix 

devoted to Instruments used in Ophthalmic Surgery 

and Examination of the Eye. 

8vo, 860 pages. Cloth, $5.00; sheep, $6.00. 



SOLD ONLY BY SUBSCRIPTION. 



HHHE work has been thoroughly revised and practically rewritten and reset. 
Much new matter has been added, and many new illustrations have been intro- 
duced. The editor has given the most scrupulous attention to the minute details, 
which serve to render the work well up to date, and the better to fit it for use as a 
text-book for practitioners and students of ophthalmology. Dr. Fuchs's great 
opportunities for clinical observation, combined with his thorough practical knowl- 
edge of anatomical and pathological science, have enabled him to write a treatise 
which, for scientific accuracy and all-round completeness, will compare favorably 
with any work of its character ; and his experience as a teacher and lecturer has 
enabled him to present the matter in a form eminently suited to the needs of the 
medical student and the general practitioner. Thus the work, while full, method- 
ical, and in all respects brought down to the latest point of ophthalmological 
science, is couched in a clear and attractive style, which renders the book very easy 
reading; and great judgment has been shown in the amount of space allotted to 
the various subjects, those that are important receiving full attention, while matters 
of a merely scientific interest or dubious points are either briefly touched upon or 
are relegated to the fine print, where those who are curious in such matters can find 
them, but where they do not interfere with the continuity of the rest of the text. 



D. APPLETON AND COMPANY, NEW YORK. 



OBSTETRICS. 

A TEXT-BOOK FOR THE USE OF STUDENTS AND 
PRACTITIONERS. 

By J. WHITRIDGE WILLIAMS, 

Professor of Obstetrics, Johns Hopkins University; Obstetrician-in-Chief to the Johns 
Hopkins Hospital; Gynecologist to the Union Protestant Infirmary, Baltimore, Md. 

SIX HUNDRED AND THIRTY ILLUSTRATIONS IN THE TEXT 
AND EIGHT COLORED PLATES. 

Cloth, S6.00; Half Leather, $6.50. 

SOLD ONLY BY SUBSCRIPTION. 



"The studies of the anatomy of the uterus and its adnexa are unique, and afford 
the student opportunity for attractive occupation in the acquirement of completer 
knowledge. The development of the ovum and placenta, has never been set forth as 
well in a work on obstetrics, according to our view, as by Williams. The illustrations 
showing the structure of the placenta are admirable. 

" In the section on obstetric surgery, beginning with induction of abortion and ac- 
couchement force, including forceps and version, Cesarean section and symphysiotomy, 
destructive operations, and ending with operative procedures which do not aim at a 
delivery, is found quite the most ample handling of operative obstetrics that has yet 
been published in such a treatise. Here, again, illustrations supplement the text in an 
instructive fashion. 

" Williams's dealing with contracted and otherwise deformed pelves, and the man- 
agement of labor in such conditions, is most satisfactory. Injuries of the birth canal, 
infection, hemorrhage, and the puerperium are all prepared by one who understands the 
greatest need of the student, and he tells him in the fewest and plainest words possible 
what he must know to obtain success in the practice of obstetrics. It is a book made 
by a clinician, which gives the most advanced exposition of the art and is a distinct 
addition to obstetric literature. 

"Much original work has been done in the way of illustration, as well as in the 
preparation of the material of many chapters, and the whole subject-matter is presented 
in an original manner. The book is a credit to both author and publisher.'' — Buffalo 
Medical Journal. 

" At a certain examination the question was asked: ' Describe the management of a 
face presentation in the M. D. P. position.' The examined men were like ' sheep before 
the shearers' — i. e., dumb. An investigation showed that the popular text-book made 
scant reference to the so-called ' undeliverable ' position. 

" Perhaps a knowledge of this fact led the reviewer of Dr. Whitridge Williams's 
work to consider, first, the description of the presentation in general, and, second, those 
of the face in particular. The admirable methods employed in explanation and the 
ample demonstrating drawings illustrating these fundamentals of obstetric knowledge 
show that the author is that rare combination, a teacher and a student ot students and 
their requirements. 

" Everything is detailed to the required minuteness, and beyond that nothing. The 
cuts and engravings are many, novel and good. They fill a definite purpose, and that 
purpose is not 'padding.' As one reads page after page the old-fashioned words, 
' Pleasure and profit,' recur to the mind. 

" It has all the earmarks of success; it is crowded with hints of practical value, and 
it shows what the trained hand and brain adopt as the best methods in overcoming the 
obstacles of parturition. Surely, if conscientious work and real merit count, we may 
expect to find this volume upon the lists of the colleges and treasured in private libra- 
ries."' — New York State Journal of Medicine. 

D. APPLETON AND COMPANY. NEW YORK. 



THE SURGICAL DISEASES 

OF THE GENITOURINARY 

ORGANS. 

By E. L. KEYES, A.M., M. D., LL. D., 

Consulting Surgeon to the Bellevue and the Skin and Cancer Hospitals ; Surgeon to 

St. Elizabeth Hospital ; formerly Professor of Genito-Urinary Surgery, 

Syphilology, and Dermatology at the Bellevue Hospital 

Medical College, etc. ; and 

E. L. KEYES, Jr., A. B., M. D., Ph.D., 

Lecturer on Genito-Urinary Surgery, New York Polyclinic Medical School and Hospital; 

Assistant Visiting Surgeon to St. Vincent's Hospital ; Physician to the 

Venereal Clinic, Out-Patient Department of the House of 

Relief of the New York Hospital, etc. 

Cloth, $5.00; half leather, $5.50. 

Sold only by Subscription. 

WITH ONE HUNDRED AND SEVENTY-FOUR ILLUSTRATIONS IN THE TEXT 
AND ELEVEN PLATES, EIGHT OF WHICH ARE IN COLORS. 

"It is certainly refreshing that a man of the experience and ability of the author 
of this volume has culled from this mass of literature the essentials, and given us in a 
well-planned volume the gist of the entire subject. 

" The book is systematically arranged, and each subject is taken up and dealt with 
in a way that makes it easily accessible to the busy practitioner. The style is explicit 
and never verbose, which, with the fine vein of humor running through it, makes it 
very enjoyable reading." — Northwestern Lancet. 

"Gonorrhea is gone into more extensively than in any other work." — Denver 
Medical Times, 

"As a text-book on Genito-Urinary Surgery it stands at the head of the publica- 
tions on the subject in the English language. Our readers wishing an up-to-date work 
on the subject can not do better than to buy this latest and newest work." — Medical 
Century. 

"The book is well illustrated, well printed, well arranged, and will be more 
popular than its predecessors." — Chicago Medical Recorder. 

"The chapters on the affections of the posterior urethra, prostate and seminal 
vesicles are especially good, and many ' pointers ' are found in the chapter on the 
'Treatment of Urethral Inflammation and their Immediate Complications.' " — Canada 
Medical Record. 

" This is a good book on an important subject. Within the compass of 800 pages 
it gives a comprehensive treatment of the various diseases of this special branch of 
surgery, and, while not discarding the good of the older work, it embraces all that is 
new in this field. "—Journal of Medicine and Science. 

"This is so well written as to be exhaustive in character, and needs little or no 
comment from the reviewer further than to mention its completeness in every par- 
ticular. " — Cincinnati Lancet-Clinic. 

D. APPLETON AND COMPANY, NEW YORK. 



JUL 8 1903 



